Persius/hicric huggingface dataset:
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Monovisc 88 MG/4 ML Syringe. 
 
You asked the Plan to pre-approve the medication. You say that the services are necessary. The Plan denied 
your request. The Plan says the member has not undergone physical therapy (PT) as yet and has not been 
treated with steroid injections. 
 
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 the medication. Our physician reviewer 
found the criteria for Monovisc injection are not met. There is no recent trial of PT for knee pain. More 
conservative measures are 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 the medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Monovisc 88 MG/4 ML Syringe.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. 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 Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found you do not have documented skilled nursing 
needs. You do not have documented skilled therapy needs. You appear to be functioning at/near your baseline. 
Daily skilled services are not required to establish a maintenance program or to prevent deterioration of your 
condition. Your care needs at this point are custodial and, as a practical matter, can be provided at a lower 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on 
May 22, 2020. 
 
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your 
request. The Plan says the documentation does not indicate services are necessary for treatment of the 
enrollee's condition. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the patient's medical 
record contains sufficient documentation of the patient's medical condition to substantiate the necessity for the 
type and quantity of items ordered and for the frequency of use.  
 
The record shows that documentation submitted did not indicate the provider discussed the need for the billed 
supply code, so the billed supply code cannot be verified. Therefore, we decided that the Plan does not have to 
pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on May 22, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a back orthosis (L0457) provided to the enrollee on June 2, 
2020. 
 
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your 
request. The Plan says the documentation does not indicate services are necessary for treatment of the 
enrollee's condition. 
 
The rules say 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. When conducting a review of a 
covered DME item, ordered by a physician, the contractor shall ensure that the physician saw the beneficiary 
and conducted a face-to-face assessment.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the durable medical equipment have not been met. Specifically, medical records do not support a 
prior face-to-face examination with the ordering physician within 6 months of ordering the DME or an 
appropriate use of telehealth. The submitted consultation notes do not support that a physical examination was 
performed. The information submitted does not confirm that Medicare coverage criteria have been met. 
Therefore, we decided that the Plan does not have to pay for a back orthosis (L0457) provided to the enrollee 
on June 2, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on 
April 3, 2020. 
 
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your 
request. The Plan says the documentation submitted did not include an itemized shipping/billing invoice to 
indicate the specific supplies, or proof of delivery for the billed date of service. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
 
 
 
 
 
 
 
The record does not contain a valid proof of delivery and relevant medical records which support medical 
necessity for the supplies provided in this case. The documentation submitted did not include an itemized 
shipping/billing invoice to indicate the specific supplies, or proof of delivery for the billed date of service. 
Therefore the billed code cannot be verified. The record shows that the Plan made several attempts to obtain 
the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for a 
lumbar-sacral orthosis (L0650) provided to the enrollee on April 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1833, L2397) 
provided to the enrollee on December 26, 2019. 
 
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your 
request. The Plan says the documentation does not indicate services are necessary for treatment of the 
enrollee's condition. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the patient's medical 
record contains sufficient documentation of the patient's medical condition to substantiate the necessity for the 
type and quantity of items ordered and for the frequency of use.  

The record shows that documentation submitted did not indicate the provider discussed the need for the billed 
supply code, so the billed supply code cannot be verified. Therefore, we decided that the Plan does not have to 
pay for a knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on December 26, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services provided to the enrollee on March 6, 2020. 
 
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 the records do not support the services 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, the CPT Code Manual definition of the denied codes is: 
 
CPT 28020: 
Arthrotomy, including exploration, drainage, or removal of loose or foreign body 
 
CPT 28022: 
Arthrotomy, including exploration, drainage, or removal of loose or foreign body 
 
CPT 28072: 
Synovectomy 
 
CPT 28240: 
tenotomy, lengthening, or release, abductor hallucis muscle 
 
CPT 28306: 
Osteotomy, with or without lengthening, shortening or angular correction, metatarsal 
 
CPT 28730: 
Arthrodesis, midtarsal or tarsometatarsal, multiple or transverse 
 
CPT 28740: 
Arthrodesis, midtarsal or tarsometatarsal, single joint 
 
CPT 29405: 
Application of short leg cast (below knee to toes) 
 
CPT 64450: 
Injection(s), anesthetic agent(s) and/or steroid; 
 
CPT 76000: 
Fluoroscopy (separate procedure), up to 1 hour physician or other qualified health care professional time 
 
We asked our coding 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 not supported by the medical records. Our coding reviewer found the 
documentation for the denied codes was reviewed and does not meet criteria. CPT codes 28020, 28022, 28240, 
28072, 28606, 28730, 28740 are not documented in the operative report to confirm requested codes. CPT 
29405, 64450, and 76000 would be procedures included in the global package. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for surgical services provided to the enrollee on March 6, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the brain 
(70553) to be provided by an out of network (OON) provider. 
 
You asked the Plan to pre-approve an MRI of the brain to be provided by an OON provider. You say that the 
services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able 
to provide these services. Therefore, coverage criteria has not been met. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a magnetic resonance imaging (MRI) of the brain (70553) to be provided by an out of network (OON) 
provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller (E2377), electronic connection 
between wheelchair controller and two or more power seating system motors (E2311), and harness for upgrade 
to expandable controller (E2313). 
 
You asked the Plan to pre-approve an expandable controller, electronic connection between wheelchair 
controller and two or more power seating system motors, and harness for upgrade to expandable controller. 
You say that the items are necessary. The Plan denied your request. The Plan says based on the documentation 
provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that certain accessories are covered when specific criteria 
is 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 an expandable controller, electronic 
connection between wheelchair controller and two or more power seating system motors, and harness for 
upgrade to expandable controller. Our reviewer says that the items are not medically necessary. Our physician 
reviewer found based on the coverage criteria, the E2377 Expandable Controller and E2313 Expandable 
Controller Harness are not medically necessary. The documentation does not reveal that you require other types 
of proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin control, head 
control, etc.) or non-proportional input devices (e.g., sip and puff, head array, etc.). You do not need to operate 
3 or more powered seating actuators through the drive control, a separate display (i.e., for alternate control 
devices), other electronic devices (e.g., control of an augmentative speech device or computer through the 
chair's drive control), or an attendant control. Your upper extremity function of independence in eating and 
grooming are sufficient for you to control any power options through their own individual switches. 
 
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 expandable controller, electronic connection between wheelchair controller 
and two or more power seating system motors, and harness for upgrade to expandable controller have not been 
met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller (E2377), 
electronic connection between wheelchair controller and two or more power seating system motors (E2311), 
and harness for upgrade to expandable controller (E2313).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips (A0120). 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that the requested additional 
transportation is necessary. The Plan denied your request. The Plan says the requested additional transportation 
trips exceed the benefit limit. Therefore, coverage criteria has not been met. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this 
case. The Plan covers a maximum of 55 one-way transportation trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips (A0120).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a seat frame, foam caster tires, tension adjustable 
bot/seat upholstery, side guards, and footrest. 
 
You asked the Plan to pre-approve a seat frame, foam caster tires, tension adjustable bot/seat upholstery, side 
guards, and footrest. You say that the items are necessary. The Plan denied your request. The Plan says based 
on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a complete manual wheelchair base includes specific 
items. 
 
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 seat frame, foam caster tires, tension 
adjustable bot/seat upholstery, side guards, and footrest. Our reviewer says that the items are not medically 
necessary. Our physician reviewer found the footrest, seat frame, padding and tires come with the wheelchair 
and the requested items would exceed the your medical need. 
 
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 seat frame, foam caster tires, tension adjustable bot/seat upholstery, side 
guards, and footrest have not been met. Therefore, we decided that the Plan does not have to pre-approve a seat 
frame, foam caster tires, tension adjustable bot/seat upholstery, side guards, and footrest.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a walk-in bathtub. 
 
You asked the Plan to pre-approve these services. You say that the jets from the tub will help with your 
arthritic pain. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a walk-in bathtub.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ubrelvy. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says self-administered drugs are not covered. 
 
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 pre-approve Ubrelvy.  
 
Benefits for these services 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services (CPT 71045) provided to the enrollee. 
 
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 an appropriate modifier to represent the services as separate was not used. 
 
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 CPT code 
71045 has a bundled relationship with code 32555 and cannot be paid as billed. This code cannot be paid as a 
separate line item without the appropriate modifier. Based on the claim submitted, Medicare billing criteria 
have not been met. Therefore, we decided that the Plan does not have to pay for radiology services (CPT 
71045) provided to the enrollee.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the physician services provided on January 15, 2020 and January 16, 
2020. 
 
You asked the Plan to pay for the physician services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that similar services have already been paid to 
a different provider on the same date of service. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. In this case, the Plan has not provided any claims showing that payment had 
been made to a different provider who performed similar services on the same date of service. We find that the 
Plan has not provided enough documentation to substantiate their reasoning for the denial of payment. 
Therefore, we decided that the Plan has to pay for the physician services provided on January 15, 2020 and 
January 16, 2020.  
 
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: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care (99308) provided on May 
13, 2020. 
 
You asked the Plan to pay for nursing facility care. You say that the services were medically necessary. The 
Plan denied your request. The Plan says Medicare guidance says once a managed care enrollee has elected 
hospice, all his or her Medicare benefits revert to fee-for-service, though the enrollee still remains on managed 
care for any additional benefits provided by his or her managed care plan, such as dental or vision coverage. 
The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date 
of election to the date of discharge or revocation. 
 
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 subsequent nursing facility care (99308) provided on May 13, 
2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on December 6, 2019. 
 
You asked the Plan to pay for the services provided. You say that the services were initiated through 
telemedicine. The Plan denied your request. The Plan says Medicare pays for a limited number of 
telecommunication services. 
 
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, 
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for 
telehealth services only if they are presented from an authorized originating site located in either a county 
outside of a MSA or a HPSA located in a rural census tract. 
  
A review of the file does not show that the telehealth service was provided in an authorized originating site. 
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute 
for an in-person encounter. Consequently, the items/services ordered following the non-covered visit are 
likewise non-covered. Therefore, we decided that the Plan does not have to pay for the lab testing services 
provided on December 6, 2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CT of the heart provided on June 10, 2020. 
 
You asked the Plan to pay for the CT scan. The Plan denied your request. The Plan says the information 
provided does not support clinical criteria. 
 
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 75571 is computed tomography, heart, without contrast 
material, with quantitative evaluation of coronary calcium. We find that CPT code 75571 is not supported in 
the medical record. In this case, there are insufficient records to show that the enrollee met at least one of the 
indications outlined in the Medicare criteria. Based on this information, we decided that Medicare rules for 
coverage of the CT scan have not been met. Therefore, we decided that the Plan does not have to pay for the 
computed tomography (CT) of the heart provided on June 10, 2020.