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

 
We decided that the Plan does not have to pre-approve implantation of a Minuteman G3R interspinous device 
(22840, 22612). 
 
You asked the Plan to pre-approve a Minuteman G3R interspinous device. You say that the requested services 
are a medical necessity for the enrollee. The Plan denied your request. The Plan says the requested services are 
experimental/investigational. 
 
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 a Minuteman G3R interspinous device. 
Our reviewer says that the requested services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that the Minuteman device is experimental. More research is needed to 
demonstrate its safety and efficacy.  
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 Minuteman G3R interspinous device have not been met. Therefore, we 
decided that the Plan does not have to pre-approve implantation of a Minuteman G3R interspinous device 
(22840, 22612).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the kyphoplasty (22514) provided on October 31, 2022. 
 
You asked the Plan to pay for the kyphoplasty. You say that  the service is medically necessary. The Plan 
denied your request. The Plan says the service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that Kyphoplasty will be considered reasonable and 
necessary when VCF is acute (less than 6 weeks) or subacute (6-12 weeks) . 
 
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 kyphoplasty. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found there is no evidence in the medical records 
that the fracture is less than 6-12 weeks old on imaging studies. 
 
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 kyphoplasty have not been met. Therefore, we decided that the Plan does 
not have to pay for the kyphoplasty (22514) provided on October 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chronic care management billed for dates of service May 17, 
2022, and June 27, 2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the 
documentation does not support the code. 
 
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 99490 billed for date of service May 17, 2022, is not supported in the medical record. 
Specifically, the medical records provided did not include this date of service. Based on this information, we 
decided that Medicare rules for coverage of the billed services have not been met. 
 
We find that codes 99439 and 99490 billed for date of service June 27, 2022, is not supported. Specifically, the 
records provided do not show that an initiating face-to-face evaluation was provided. 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 chronic care management billed for dates of service May 17, 
2022, and June 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95908 billed for date of service August 25, 
2022. 
 
You asked the Plan to pay for procedure code 95908. The Plan denied your request. The Plan says payment for 
code 95908 is bundled into payment for code 95861. 
 
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 95908 
is a column II code to column I code 95861 with a modifier indicator of 0. The column II code is therefore not payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code 95908 billed for date of service August 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical extractions for tooth numbers 17 and 29. 
 
You asked the Plan to pre-approve the dental services. You say that you are in extreme pain and need the 
extractions. The Plan denied your request. The Plan says this service is not a covered benefit under your dental 
plan. 
 
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 pre-approve 
surgical extractions for tooth numbers 17 and 29.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve treatment with Keytruda (J9271). 
 
You asked the Plan to pre-approve Keytruda. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says that the requested drug has been prescribed for an off-
label, not medically accepted use. 
 
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 Keytruda. Our reviewer says that the 
requested treatment is medically reasonable and necessary in this case. Our physician reviewer found that the 
requested use of Keytruda is not FDA-approved for the enrollees diagnosis. The use is not supported by one of 
the major drug compendia; however, the use is supported by clinical research that appears in a Medicare-
approved medical journal. The documentation supports that the requested drug is safe and effective and 
otherwise reasonable and necessary 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 Keytruda have been met. Therefore, we decided that the Plan has to pre-approve 
treatment with Keytruda (J9271).  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95941 billed for date of service August 5, 
2022. 
 
You asked the Plan to pay for procedure code 95941. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says this code is not payable as billed. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 
procedure code 95941 is an add-on code and has not been billed with an appropriate primary procedure code. 
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 95941 billed for date of service August 5, 2022.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to reduce the copayment for the visual field examination. We decided that the 
Plan does not have to waive the copayment for the visual field examination.  
 
You asked the Plan to waive the copayment for the visual field examination (92083) provided on January 27, 
2023. You say that you feel you should not have to pay the $50.00 copay, as you were not advised the provider 
would have a copay and the facility would as well. You also say that you cannot afford to pay this much for 
one visit. The Plan says that this cost sharing was charged correctly. 
 
We decided that the Plan has to reduce the copayment for the visual field examination.  
 
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 enrollees must pay a $3 copayment for Medicare-covered non-radiological 
diagnostic tests under the Outpatient diagnostic tests and therapeutic services and supplies benefit category.  
 
The Plan says you must pay a $50 copayment for Vision care. Based on the Plan contract, however, you cannot 
be asked to pay more than a $3 copayment for the visual field examination which falls within the Outpatient 
diagnostic tests and therapeutic services and supplies benefit category. Therefore, we decided that the Plan has 
to reduce the copayment for the visual field examination.  
 
We also decided that the Plan does not have to waive the copayment for the visual field examination. 
 
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 $3 
copayment for the visual field examination. Therefore, we decided that the Plan does not have to waive the 
copayment for the visual field examination. 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs inpatient rehabilitation to learn 
how to walk with a new prosthesis. The Plan denied your request. The Plan says the IRF services requested 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 that the complexity of the enrollee's nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. There is not a reasonable expectation that this enrollee 
will be able to fully participate in  and benefit from  the intensive rehabilitation therapy program provided in 
an IRF. 
 
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: Supplemental Benefit
Decision: Partially Favorable

 
You asked the Plan to pay more for the frames (V2020), photochromatic tint (V2744), anti-reflective coating 
(V2750), progressive lenses (V2781), and high index lenses (V2782) purchased on December 29, 2022. You 
say that you do not see how you owe $579.00. You also say that ironically as of January 8, 2023, you still do 
not have a pair of glasses with your prescription for the lens. The Plan says that the maximum benefit has been 
exceeded. The Plan also says this claim was processed correctly. 
 
  We decided that the Plan has to pay $119.68 more for the eyewear.  
 
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 offers a $300 benefit toward the purchase and fitting of eyeglasses and pair of lenses or 
contact lenses once per calendar year. 
 
We looked at the file and the Plan's rules. Specifically, the record shows that the Plan only paid $180.32 toward 
this purchase. Write-offs and disallowed amounts are not benefits that are actually paid by the Plan. Based on 
this information, we decided that the Plan's rules for coverage of the eyewear have been met. The remaining 
balance of your eyewear benefit is $119.68. Therefore, we decided that the Plan has to pay $119.68 more for 
the eyewear.  
 
We also decided that the Plan does not have to pay in full for the eyewear. 
 
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 offers a $300 benefit toward the purchase and fitting of eyeglasses and pair of lenses or 
contact lenses once per calendar year. 
 
We looked at the file and the Plan's rules. The Plan must pay the remaining $119.68 of your eyewear benefit. 
Once this amount is paid, your eyewear allowance will be exhausted. Based on this information, we decided 
that the Plan's rules for coverage of the eyewear have not been met. Therefore, we decided that the Plan does 
not have to pay in full for the eyewear. 
 
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 a lumbar kyphoplasty procedure (22514). 
 
You asked the Plan to pre-approve a lumbar kyphoplasty. You say that the requested services are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested services are 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 a lumbar kyphoplasty. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there is no record of conservative measures, including a brace trial. 
 
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 lumbar kyphoplasty have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a lumbar kyphoplasty procedure (22514).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urinary tract infection (UTI) panel provided on 
November 4, 2022, and billed with codes 87481, 87500, 87641, 87651, 87653 and 87798. 
 
You asked the Plan to pay for the UTI panel. You say that this test was medically necessary and is supported in 
the medical record. The Plan denied your request. The Plan says this panel was not billed in accordance with 
Medicare guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that a test panel is a single test with multiple 
components and is characterized by a single unit of service (UOS =1). A panel cannot be unbundled and billed 
as individual components regardless of the fact that the test reports multiple individual pathogens and/or 
targets. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the UTI panel have not been met. Specifically, the service at issue is a test panel which was 
unbundled and billed as individual components. Therefore, we decided that the Plan does not have to pay for 
the urinary tract infection (UTI) panel provided on November 4, 2022, and billed with codes 87481, 87500, 
87641, 87651, 87653 and 87798.
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 impatient rehabilitation may safely and effectively 
manage the enrollee's medical needs and current risks. The Plan denied your request. The Plan says the enrollee 
does not meet the criteria for admission to an Inpatient Rehabilitation Facility. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for injection(s); single tendon sheath, or ligament, aponeurosis (eg, plantar 
"fascia") rendered on June 14, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that the denied code is part of the primary procedure and not eligible for separate payment. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
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 services Our reviewer says that the 
services at issue in this case were supported by the medical records. Our physician reviewer found that the 
record supports that the injections reported were at separate sites and were not reported for the administration 
of local anesthesia. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for 
injection(s); single tendon sheath, or ligament, aponeurosis (eg, plantar "fascia") rendered on June 14, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87150, 87481, 87641, 87653, and 87798, 
billed for date of service October 17, 2022. 
 You asked the Plan to pay for procedure codes 87150, 87481, 87641, 87653, and 87798. The Plan denied your 
request. The Plan says payment for codes 87150, 87481, 87641, 87653, and 87798, is bundled. 
 
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 87150 
is a column II code to column I code 87500. We have also confirmed that codes 87481, 87641, 87653, and 
87798, are column II codes to column I code 87150. 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 87150, 87481, 87641, 87653, and 
87798, billed for date of service October 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95937 billed for date of service September 
15, 2022. 
 
You asked the Plan to pay for procedure code 95937. You say that this service was medically necessary and is 
supported as billed. The Plan denied your request. The Plan says the code used to report the services provided 
is not supported in the medical record. 
 
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 procedure code 95937. Our reviewer says that this code is 
not supported in the medical record. Our reviewer found train of four testing is included in intraoperative 
neuromonitoring and should not be reported with code 95937. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 95937 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 95937 billed for date of service September 15, 2022.