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

We decided that the Plan does not have to pay for diabetics only, prefabricated, multiple density insert (A5512) 
and diabetics only, fitting (including follow-up), custom preparation and supply of off-the-shelf depth-inlay 
shoe manufactured to accommodate multi-density insert (A5500) provided December 30, 2019. 
 
You asked the Plan to pay for the diabetic foot orthotics. You say that each member is allowed one pair of 
diabetic shoes with a set of inserts per calendar year. According to several of the Plan's representatives, the 
enrollee did not receive a pair of in 2019. The Plan denied your request. The Plan says the maximum benefit 
has been exhausted. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The records show that the plan had already paid for diabetic foot orthotics on September 19, 2019 for date of 
service September 1, 2019. Therefore, we decided that the Plan does not have to pay for diabetics only, 
prefabricated, multiple density insert (A5512) and diabetics only, fitting (including follow-up), custom 
preparation and supply of off-the-shelf depth-inlay shoe manufactured to accommodate multi-density insert 
(A5500) provided December 30, 2019.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for radiology services (CPT 70450) received on May 24, 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 that the services were billed with an inpatient place of service 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
The services were provided by a contract provider. The service facility was an in-network medical center, and 
the billing provider is the radiology group for that in-network medical center. You did not have any control 
over how these services were billed. The file does not show that the Plan provided notice that the services 
would not be covered. Under Medicare rules, this means the services is considered approved by the Plan. 
Therefore, we decided that the Plan has to pay for radiology services (CPT 70450) received on May 24, 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa (J7323). 
 
You asked the Plan to pre-approve Euflexxa. You say that the enrollee has tried and failed over the counter 
drugs. The Plan denied your request. The Plan says the step therapy requirements have not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Euflexxa. Our reviewer says that the 
requested drug is not medically necessary. Our physician reviewer found the documentation shows that the 
enrollee has not trialed the required viscosupplemental treatments such as Orthovisc and Monovisc. The 
reviewer found that the documentation does not outline contraindications or reasons these medications were not 
considered or that the plan's required drugs would likely be less effective and/or likely have adverse effects for 
the enrollee. The reviewer found that without the support of the documentation, Euflexxa has not met the 
criteria for step therapy.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa (J7323).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the bone graft (21210) and impressions (21085). 
 
You asked the Plan to pre-approve the bone graft and impressions. You say that you would like reconsideration 
based on the records submitted. The Plan denied your request. The Plan says Medicare does not cover routine 
dental services and the Plan does not provide coverage for supplemental dental benefits. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement 
of your teeth or the structures directly supporting the member?s teeth. These are dental services that are not 
covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve the bone 
graft (21210) and impressions (21085).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the 20mg/0.4ml Kesimpta Pen (J3590). 
 
You asked the Plan to pre-approve the Kesimpta Pen. You say that you would like reconsideration because this 
drug is medically necessary. The Plan denied your request. The Plan says this drug is not covered for the 
member's condition under Medicare Part B. 
 
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 the 20mg/0.4ml Kesimpta 
Pen (J3590).  
 
Benefits for the Kesimpta Pen 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ambulance transport. 
 
You asked the Plan to pre-approve ambulance transport. You say that the requested non-emergency ambulance 
transport to the approved SNF is medically necessary. The Plan denied your request. The Plan says the enrollee 
is approved to transfer to a different SNF. However, as the enrollee is receiving appropriate care in the current 
facility, non-emergent ambulance transport is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve ambulance transport. Our reviewer says 
that the requested non-emergency ambulance transport to the approved SNF is not medically necessary. Our 
physician reviewer found based on the medical records provided there is no documentation that the enrollee's 
clinical condition is such that other methods of transport are contraindicated. The enrollee is ambulating with a 
hemi walker with moderate assistance and there is no documentation of any acutely unstable cardiac, 
pulmonary or neurologic conditions. There is no documentation that a wheelchair van (or similar means of 
transportation) would be contraindicated for her transport. There is no documentation that the requested 
ambulance transport from one skilled nursing facility to another skilled nursing facility is medically reasonable 
and necessary for the enrollee in this case. 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ambulance transport have not been met. Therefore, we decided that the Plan 
does not have to pre-approve ambulance transport.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from 
August 31, 2019 to September 26, 2019. 
 
You asked the Plan to pay for home health services. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says the provider did not bill with an appropriate Q 
code on the claim. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, the 
submitted claim does not include the required Q code. Therefore, we decided that the Plan does not have to pay 
for the home health services provided to the enrollee from August 31, 2019 to September 26, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller (E2377), expandable controller 
harness (E2313), and electro connect (E2311) to control power tilt, recline and power elevating leg rests 
through the joystick. 
 
You asked the Plan to pre-approve an expandable controller (E2377), expandable controller harness (E2313), 
and electro connect (E2311) to control power tilt, recline and power elevating leg rests through the joystick. 
You say that the requested expandable controller (E2377), expandable controller harness (E2313), and electro 
connect (E2311) to control power tilt, recline and power elevating leg rests through the joystick are medically 
necessary. The Plan denied your request. The Plan says the requested expandable controller (E2377), 
expandable controller harness (E2313), and electro connect (E2311) to control power tilt, recline and power 
elevating leg rests through the joystick 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 an expandable controller (E2377), 
expandable controller harness (E2313), and electro connect (E2311) to control power tilt, recline and power 
elevating leg rests through the joystick. Our reviewer says that the requested expandable controller (E2377), 
expandable controller harness (E2313), and electro connect (E2311) to control power tilt, recline and power 
elevating leg rests through the joystick are not medically necessary. Our physician reviewer found based on the 
medical records provided there is no documentation that the enrollee has a covered indication for the requested 
expandable controller (E2377), expandable controller harness (E2313), and electro connect (E2311) to control 
power tilt, recline and power elevating leg rests through the joystick per LCA A52504. There is no 
documentation that the requested expandable controller (E2377), expandable controller harness (E2313), and 
electro connect (E2311) to control power tilt, recline and power elevating leg rests through the joystick are 
medically reasonable and necessary for the enrollee in this case. 
 
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 (E2377), expandable controller harness (E2313), and 
electro connect (E2311) to control power tilt, recline and power elevating leg rests through the joystick have 
not been met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller 
(E2377), expandable controller harness (E2313), and electro connect (E2311) to control power tilt, recline and 
power elevating leg rests through the joystick.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a toric IOL. 
 
You asked the Plan to pre-approve a toric IOL. The Plan denied your request. The Plan says this is not a 
covered service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and 
eyewear.  
 
The services you asked the Plan to pre-approve are considered routine vision services or eyewear. The Plan 
does not cover IOL upgrades. Only the standard IOL is covered. Therefore, we decided that the Plan does not 
have to pre-approve a toric IOL.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay for the services (CPT 31629) provided on November 20, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that the billed service 
cannot be verified. 
 
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 31629 is "Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with 
transbronchial needle aspiration biopsy(s), trachea, main stem and/or lobar bronchus(i)". 
 
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 use 
of CPT code 31629 is supported by the records provided. Our coding reviewer found that the operative report 
documents "Multiple biopsy specimen with over 5 passes in each lymph node station mentioned above were 
done under direct visualization with EBUS". 
 
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 been met. Therefore, we decided that the Plan has to pay for 
the services (CPT 31629) provided on November 20, 2019.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the commode chair, mobile or stationary, with fixed 
arms (E0163). 
 
You asked the Plan to pre-approve the commode chair. You say that you have a commode in your bedroom but 
you would like another commode to be covered so that you don't have to move the one from your bedroom to 
the family room every time the enrollee changes rooms. The Plan denied your request. The Plan says the 
enrollee does not meet the Medicare criteria for the requested item. 
 
The Plan must follow Medicare rules. The rules say that a commode chair is covered only for enrollees who are 
confined to a bed or room. 
 
The file does not show that the enrollee is confined to a bed or room as defined by Medicare rules. Therefore, 
we decided that the Plan does not have to pre-approve the commode chair, mobile or stationary, with fixed 
arms (E0163).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on February 18, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 
billed incorrectly. 
 
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 the requested CPT codes are not supported in the medical record. Specifically, the records 
provided do not show that lab services were performed with blood sampling. The records show that a urine 
specimen was collected. The billed services cannot be verified. 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 the lab services provided on February 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ACell skin sub graft. 
 
You asked the Plan to pre-approve ACell skin sub graft. You say that the requested ACell skin sub graft is 
medically necessary. The Plan denied your request. The Plan says the requested ACell skin sub graft is not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve ACell skin sub graft. Our reviewer says 
that the requested ACell skin sub graft is not medically necessary. Our physician reviewer found the enrollee 
has undergone multiple facial reconstructive surgeries. It is documented that soft tissue closure on 8/28/20 
resulted in significant improvement, however there is a persistent 2x3mm defect on the dorsum of the nose 
with active infection and exposed hardware.  
 
ACell is a urinary bladder matrix which is considered investigational at this time. The documentation does not 
support that the requested ACell skin sub graft is medically reasonable and necessary for the enrollee's 
condition for the enrollee in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ACell skin sub graft have not been met. Therefore, we decided that the Plan 
does not have to pre-approve ACell skin sub graft.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and the smoking and tobacco use cessation 
counseling visit services provided on June 25, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for the office visit and the smoking and tobacco use cessation counseling visit 
services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The 
Plan says the services rendered are not a covered benefit. 
 
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 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. 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 and the smoking and tobacco use 
cessation counseling visit services provided on June 25, 2020 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Repatha SureClick. 
 
You asked the Plan to pre-approve Repatha SureClick. You say that you want the enrollee treated with this 
drug. The Plan denied your request. The Plan says this drug is not covered under the enrollee's Medicare Part B 
benefit. 
 
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 Repatha SureClick.  
 
Benefits for Repatha SureClick 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 pay for the home infusion therapy services coded S9328 provided 
from 
 
You asked the Plan to pay for the home infusion therapy services. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable. 
 
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 S9328 is home infusion therapy, implanted pump pain 
management infusion; administrative services, professional pharmacy services, care coordination, and all 
necessary supplies and equipment (drugs and nursing visits coded separately), per diem. 
 
We find that CPT code S9328 is not supported in the medical record. Specifically, this code has a status code 
of "I". A status code of I means that this code is not valid for Medicare purposes. Medicare uses another code 
for reporting of, and payment of these services. Based on this information, we decided that Medicare rules for 
coverage of the home infusion therapy services have not been met. Therefore, we decided that the Plan does 
not have to pay for the home infusion therapy services coded S9328 provided from
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that you would like reconsideration because you 
suffer from pain in your feet. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.