Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (K0554). 
 
You asked the Plan to pre-approve the continuous glucose monitor. You say that the continuous glucose 
monitor is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet 
coverage criteria for continued coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that in order for a continuous glucose monitor to be 
covered, the enrollee must be insulin-treated with multiple (three or more) daily injections of insulin.  
 
We looked at the file and Medicare rules. The record shows you do not use injected insulin. Based on this 
information, we decided that Medicare rules for coverage of the continuous glucose monitor have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (K0554).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve outpatient mental health treatment to be provided by the 
requested provider. 
 
You asked the Plan to pre-approve the outpatient mental health treatment. You say that you have tried to find a 
participating provider, but you never received a response from the messages you left with the providers. You 
say this provider is within walking distance and you do not have to take a car service to get to the provider's 
office. The Plan denied your request. The Plan says members must receive care from an in-network provider. 
In most cases, care members receive from an out-of-network provider will not be covered. If the member needs 
medical care that Medicare requires our plan to cover and the providers in our network cannot provide this 
care, the member can get this care from an out-of-network provider. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve outpatient 
mental health treatment to be provided by the requested provider.
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 records provided support the need for IRF care. 
The Plan denied your request. The Plan says the guidelines for coverage of IRF care have not been met. The 
Plan says that the enrollee can safely receive the services needed in the current hospital setting. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 enrollee is medically stable after a hip fracture and surgery with no evidence of 
need for supervision by a physical medicine and rehabilitation physician three times a week or needing acute 
rehab nursing care. The documentation does not support that there is a need for an intensive therapy program 
with 3 hours a day and an interdisciplinary approach to rehab care at the current level of function described 
above. The enrollee does not meet the CMS coverage criteria for an IRF admission due to lack of medical 
complexity. The enrollee's rehab needs can be met in an alternate, less intense setting such as in a skilled 
nursing facility. 
 
 
 
 
 
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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room (ER) services rendered on October 25, 
2019. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 99285 is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99285 is Level 5 emergency department visit for 
evaluation and management of patient with problem immediately threatening life, including comprehensive 
history and physical examination, and medical decision-making of high complexity. 
 
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 these services. Our reviewer says that 
procedure code 99285 is not supported. Our physician reviewer found billing CPT 99285 requires the 
documentation of a comprehensive history, comprehensive examination and medical decision making of high 
complexity.  Furthermore, the complaint is usually one of great severity, which poses an immediate risk to the 
health of the patient.  In this case, the enrollee was seen in the ER for epigastric pain one month after a 
complete cardiac evaluation.  While basic cardiac testing was repeated, the provider clearly noted that the pain 
was clinically believed to be gastrointestinal in origin.  Higher level testing and treatments were not provided.  
As such, the billing of CPT 99285 is not supported. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the emergency room (ER) services rendered on October 25, 2019.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for the interpretation of a knee x-ray (up to 2 views) provided on June 4, 2020.

You asked the Plan to pay for the knee x-ray interpretation. You say that this is not a duplicate charge and should be paid. The Plan denied your request. The Plan says that code 73560 is a Column II code in relation to code 73564 which was billed by another provider in the group practice on this date of service. As this is included in payment for a more extensive service, this denial is correct.

The Plan must follow Medicare rules. Medicare rules say that PTP edits exist to prevent improper payment for services which should not be reported together. These edits are based on services provided by the same physician to the same beneficiary on the same date of service.

In this case, the Column I code was provided by a different physician. A PTP edit cannot be applied to this situation. The provider has submitted documentation to show that a lateral and AP view of the right knee were reviewed by the physician at issue in this case. The denial of payment for this service is not supported. Therefore, we decided that the Plan has to pay for the interpretation of a knee x-ray (up to 2 views) provided on June 4, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided to the enrollee on April 24, 2020 
and billed under code 86077-59. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says while code 86077 was paid, code 86077-59 could not be paid as billed. The Plan says 
that CMS has established units of service edits referenced to as Medically Unlikely Edit(S) (MUEs)An MUE 
for a HCPCS/CPT code is the maximum number of units of service (UOS) under most circumstances allowable 
by the same provider for the same beneficiary on the same date of service. The Plan says that Medicare 
Guidance says CPT 86077 was not billed in accordance with Medicare National Correct Coding Initiative 
Policy - Medically Unlikely Edits (MUE). The Plan says that CPT 86077 has an MUE value of 1, however the 
provider billed two units when they billed 86077 and 86077-59.  
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. In this case, the MUE for CPT code 86077 is 
1. You submitted 2 units of this code, exceeding the MUE. Based on this information, we decided that 
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not 
have to pay for physician services provided to the enrollee on April 24, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided to the enrollee from October 
1, 2019, to October 31, 2019. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says Medicare billing criteria are not met. The Plan says that a RAP claim was not billed, and 
the billed claim was missing Q-codes.   
 
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 claim submitted has coding 
errors preventing payment. The Plan states a corrected claim would be reviewed if submitted. Medicare rules 
for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for 
home health services provided to the enrollee from October 1, 2019, to October 31, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a knee orthosis (L1843). 
 
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 request is not medically necessary because your records show you do not have recent 
injury or surgery or objective evidence of instability. 
 
The Plan must follow Medicare rules. Medicare rules say that knee orthoses defined by code L1843 are 
covered if the beneficiary has had recent injury to or a surgical procedure on the knee(s) or when knee 
instability is documented by examination of the beneficiary and objective description of joint laxity. The record 
sent by the provider indicates knee pain but the records do not demonstrate recent injury or surgery or that 
instability of the knee was found on physical exam. Therefore, we decided that the Plan does not have to pay 
for a knee orthosis (L1843).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided by you on March 27, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were following the COVID executive 
order for treatment in place. The Plan denied your request. The Plan says these services are not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on March 27, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided by you on March 
27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a second confirmatory medial branch block. 
 
You asked the Plan to pre-approve a second confirmatory medial branch block. You say that you would like the 
Plan to reconsider their denial. The Plan denied your request. The Plan says you do not meet Medicare criteria 
for the requested confirmatory medial branch block. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. The file shows that your first medial branch block only produced 
between 25% and 50% relief of primary pain. Medicare requires at least an 80% relief of primary pain in order 
to approve a second confirmatory medial branch block. Based on this information, we decided that Medicare 
rules for coverage of a second confirmatory medial branch block have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a second confirmatory medial branch block.
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 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 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 medically necessary. Our physician reviewer found the enrollee is 
currently undergoing treatment at an acute care hospital (ACH) for pneumonia following recent gallbladder 
surgery. The enrollee was transiently intubated/ventilated but is no longer intubated/ventilated. There is no 
evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed 
to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee 
can remain at the current ACH until such time no acute services are required. 
 
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an inpatient hospital admission for planned total knee 
arthroplasty (TKA). 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that you have surgery in less than a 
week. The Plan denied your request. The Plan says the inpatient level of care is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve acute inpatient hospital care. Our 
reviewer says that the inpatient level of care is not medically necessary. Our physician reviewer found you are 
approved for a left TKA. The requested overnight stay can be done at the outpatient level of care. The records 
do not support a reasonable expectation that you will require at least two midnights of inpatient hospital care 
for the approved surgery. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an inpatient hospital admission for planned total knee arthroplasty (TKA).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve therapeutic parenteral drugs (D9612). 
 
You asked the Plan to pre-approve therapeutic parenteral drugs (D9612). 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 Plan's 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 
therapeutic parenteral drugs (D9612).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acupuncture visits. 
 
You asked the Plan to pre-approve acupuncture. You say that acupuncture will help you with the numbness of 
your nerves as well as your balance and coordination. The Plan denied your request. The Plan says the denial of 
authorization for this service is correct, because you have not been diagnosed with and are not being treated for 
chronic lower back pain. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, you are requesting acupuncture for treatment of 
peripheral neuropathy which is not a diagnosis for which Medicare covers acupuncture at this time. Therefore, 
we decided that the Plan does not have to pre-approve acupuncture visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician's services to be provided by an out-of-network 
orthopedic specialist. 
 
You asked the Plan to pre-approve the physician's services to be provided by an out-of-network orthopedic 
specialist. You say that the Plan physician administered a Synvisc injection incorrectly. The Plan denied your 
request. The Plan says members are contractually obligated to obtain services from network providers and there 
are treatment and services available within Plan. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve 
physician's services to be provided by an out-of-network orthopedic specialist.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve percutaneous laminotomy/laminectomy for 
decompression of neural elements (MILD procedure). 
 
You asked the Plan to pre-approve MILD procedure. You say that this service is covered by Medicare as part 
of a clinical study, not a clinical trial, so it should be covered by the Plan. The Plan denied your request. The 
Plan says the denial of authorization for this service is correct, because coverage of service within this clinical 
trial should be submitted to Original Medicare and is not covered by the Plan. 
 
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of 
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as 
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in 
Original Medicare and the plan cost-sharing for the same services. In this case, you asked the Plan to pre-approve MILD procedure as part of a clinical trial. The Plan does not cover routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to pre-approve percutaneous laminotomy/laminectomy for decompression of neural elements (MILD procedure).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Osphena, 60 mg tablet. 
 
You asked the Plan to pre-approve Osphena. You say that the enrollee has trialed multiple other medications 
that have only minimally or acutely relieved her symptoms. You also say that the enrollee's symptoms are best 
controlled on the requested drug. The Plan denied your request. The Plan says this drug is not covered for your 
condition by the Plan. The Plan says the requested drug is considered self-administered. 
The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Osphena, 60 mg tablet.  
 
Benefits for Osphena 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Botox. 
 
You asked the Plan to pre-approve these services. You say that the enrollee has persistent nausea interfering 
with lifestyle and function. 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 a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the submitted records support that the 
enrollee does not have documented pyloric stenosis. There is no documentation of gastroparesis by gastric 
emptying scan or other methods. The records do not support that Botox is reasonable or medically necessary 
for the enrollee at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Botox.