Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services provided on March 26, 2020. 
 
You asked the Plan to pay for anesthesia for percutaneous image guided procedures on the spine and spinal 
cord; therapeutic (01936). You say that the service was medically necessary. The Plan denied your request. The 
Plan says minor pain procedures under most routine circumstances do not require anesthesia care other than 
local anesthesia. 
 
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 pay for Anesthesia for percutaneous image guided 
procedures on the spine and spinal cord; therapeutic (01936). Our reviewer says that the requested 
items/services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found Epidural steroid injections are typically performed in an ambulatory setting without sedation and without 
the services of an anesthesiologist.  There is nothing contained in the submitted documentation to warrant 
anesthesia services for this procedure. The provided medical records do not support the use of anesthesia for 
this procedure. The requested anesthesia care was not medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Anesthesia for percutaneous image guided procedures on the spine and spinal 
cord; therapeutic (01936) have not been met. Therefore, we decided that the Plan does not have to pay for 
anesthesia services provided on March 26, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiology services provided on May 18, 2020. 
 
You asked the Plan to pay for the radiology services. The Plan denied your request. The Plan says payment for 
these services is included in the SNF PPS. 
 
The Plan must follow Medicare rules. Medicare rules say that The SNF must bill radiology services furnished 
its inpatients in a Part A covered stay and payment is included in the SNF Prospective Payment System (PPS).  
 
We looked at the file and Medicare rules. Per Medicare rules, payment for these services is included in the SNF 
PPS, and separate payment cannot be made. Based on this information, we decided that Medicare rules for 
coverage of the radiology services have not been met. Therefore, we decided that the Plan does not have to pay 
for the radiology services provided on May 18, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Monovisc (hyaluronate injection). 
 
You asked the Plan to pre-approve Monovisc. You say that the requested drug is medically necessary. The Plan 
denied your request. The Plan says you are required to try other medicine of the same type that is on the 
formulary. The Plan says there is no evidence the other medicines were trialed. The Plan also says that the 
requested drug is not medically necessary. 
 
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 Monovisc. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found that criteria for a knee visco injection has not 
been met. The reviewer found there is no documentation of trial and failure of first line injection drugs. The 
 
 
reviewer also found that recent literature shows that visco injections are not effective for the treatment of knee 
pain from DJD. Therefore, the reviewer round that the injection is not medically 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 Monovisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Monovisc (hyaluronate injection).
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 failed Monovisc. The Plan denied 
your request. The Plan says step therapy criteria 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 
criteria for coverage of Euflexxa have not been met. Our physician reviewer found the documentation shows 
that the enrollee has not trialed Orthovisc.   Step therapy, as outlined by the plan, requires Orthovisc be trialed 
before the requested drug can be approved. The documentation does not outline contraindications or reasons 
this medication was not considered. 
 
 
 
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on November 26, 2019. 
 
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 If no bilateral code is provided and the condition 
is bilateral, assign separate codes for both the left and right side. If the side is not identified in the medical 
record, assign the code for the unspecified side.  
 
We looked at the file and Medicare rules. In this case, left and right diagnosis codes were billed. However, if a 
bilateral code exists, then a provider should not report both sides individually. 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 services provided on November 26, 2019.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a crown (D2740) for tooth # 19. 
 
You asked the Plan to pre-approve the dental service. You say that tooth # 19 has many cracks. The Plan 
denied your request. The Plan says that the tooth does not have significant breakdown. The Plan also says the 
requested crown is not medically necessary. 
 
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. The Plan covers the dental 
service when the services are medically necessary and reasonable. 
 
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 dental service. Our reviewer says 
that the service is medically necessary. Our physician reviewer found the provided x-ray and intra oral photo 
reveal an existing single surface amalgam restoration and visible crack lines. The reviewer found that in order 
to attempt conventional restoration of a tooth with widespread cracking, extensive destruction of the tooth 
would occur without any strengthening of the remaining structure. The reviewer found that the end result 
would be a higher likelihood of gross fractures and possible tooth loss. Therefore, the reviewer found that given 
the particular presentation of this case, a full coverage restoration would be reasonable and medically 
necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental service have been met. Therefore, we decided that the Plan has to 
pre-approve a crown (D2740) for tooth # 19.  
 
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 the anesthesia services provided on February 10, 2020. 
 
You asked the Plan to pay for anesthesia for percutaneous image guided procedures on the spine and spinal 
cord; therapeutic (01936). You say that the service was medically necessary. The Plan denied your request. The 
Plan says minor pain procedures under most routine circumstances do not require anesthesia care other than 
local anesthesia. 
 
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 pay for anesthesia for percutaneous image guided 
procedures on the spine and spinal cord; therapeutic (01936). Our reviewer says that the services were not 
considered medically reasonable and necessary in this case. Our physician reviewer found epidural steroid 
injections are typically performed in an ambulatory setting without sedation and without the services of an 
anesthesiologist.  There is nothing contained in the submitted documentation to warrant anesthesia services for 
this procedure. The provided medical records do not support the use of anesthesia for this procedure. The 
requested anesthesia care was not medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of anesthesia for percutaneous image guided procedures on the spine and spinal 
cord; therapeutic (01936) have not been met. Therefore, we decided that the Plan does not have to pay for the 
anesthesia services provided on February 10, 2020.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to provide Bevacizumab injections for left eye. 
 
You asked the Plan to provide Bevacizumab injections (J9035). You say that you want the enrollee treated with 
this drug. The Plan denied your request. The Plan says that the enrollee does not have a qualifying diagnosis for 
Bevacizumab injections. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 provide Bevacizumab injections (J9035). Our 
reviewer says that the treatment is medically necessary. Our physician reviewer found treatment with 
Bevacizumab is medically necessary due to proliferative disease in the setting of retinal vascular disease and 
diabetes. The treatment is the standard of care for this condition. The health plan incorrectly denied coverage 
based on the absence of macular edema in the non-treated (left) eye.  Review of the office notes shows clearly 
that this is the correct treatment and should be covered. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Bevacizumab injections (J9035) have been met. Therefore, we decided that the 
Plan has to provide Bevacizumab injections for left eye.  
 
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 pay for the observation care services coded 99217 and the 
cardiovascular stress test services coded 93018 provided on November 18, 2019. 
 
You asked the Plan to pay for the observation care services and the cardiovascular stress test services. You say 
that you would like the plan to reconsider their denial. 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 CPT codes 99217 and 93018 are not supported in the medical record. Specifically, procedure code 
99217 requires a modifier when billed with procedure code 93018. Based on this information, we decided that 
Medicare rules for coverage of the observation care services and the cardiovascular stress test services have not 
been met. Therefore, we decided that the Plan does not have to pay for the observation care services coded 
99217 and the cardiovascular stress test services coded 93018 provided on November 18, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 92 cans of Boost nutrition (B4150). 
 
You asked the Plan to pre-approve Boost nutrition. You say that after having neck surgery you had instructed 
the representative to stop processing the order as your surgical team was making changes. You have not 
received the 92 cans of Boost so she must have been successful. The Plan denied your request. The Plan says 
this item is not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. 
 
The items you asked the Plan to pre-approve are nutritional supplements. Therefore, we decided that the Plan 
does not have to pre-approve 92 cans of Boost nutrition (B4150).
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 have had bad feed your entire life. You also 
say that you have a hard time walking without the orthotics. 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.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve destruction by neurolytic agent, genicular nerve 
branches including imaging guidance, CPT Code 64624) for the enrollee. 
 
You asked the Plan to pre-approve this treatment. You say that this treatment is medically necessary. The Plan 
denied your request. The Plan says this treatment is not covered by Medicare. 
 
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 this 
treatment. Our reviewer says that the requested services are not considered medically reasonable and necessary 
in this case. Our physician reviewer found that this procedure is still considered experimental/ investigational at 
this time.  Therefore, the request is deemed not medically necessary or reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this treatment have not been met. Therefore, we decided that the Plan does not 
have to pre-approve destruction by neurolytic agent, genicular nerve branches including imaging guidance, 
CPT Code 64624) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of interlaminar/interspinous process 
stabilization/distraction device w/o open decompression or fusion including guidance when performed (22869). 
 
You asked the Plan to pre-approve posterior interspinous decompression spacer procedure. You say that you 
are appealing the denial of coverage for the posterior interspinous decompression spacer procedure. This 
treatment is medically necessary and appropriate for this stage of the disease progression. The Plan denied your 
request. The Plan says the enrollee is not enrolled in a Medicare approved clinical research study and this 
procedure is considered investigational and is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of posterior interspinous decompression spacer procedure have not been met. Therefore, we decided 
that the Plan does not have to pre-approve insertion of interlaminar/interspinous process 
stabilization/distraction device w/o open decompression or fusion including guidance when performed (22869).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the outpatient surgery procedure coded as 42806, 
31237, 31040 and 61782 to be provided by an out of network (OON) provider. 
 
You asked the Plan to pre-approve the outpatient surgery procedure. You say that you know that this provider 
is out of network, but this is the only provider that performs this type of procedure and you have worked with 
him for some time and you feel comfortable. The Plan denied your request. The Plan says enrollees must 
receive their medical services from an in-network provider with the exception being urgent or emergent 
services. Non-emergent services with non-contracted providers require prior authorization before services 
being rendered. 
 
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 
the outpatient surgery procedure coded as 42806, 31237, 31040 and 61782 to be provided by an out of network 
(OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a replacement partial denture. 
 
You asked the Plan to pre-approve a replacement partial denture. You say that You say that you lost the partial 
denture that was provided on July 5, 2018. The Plan denied your request. The Plan says partial dentures are 
only covered every 5 years. 
 
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. The Plan covers a replacement 
partial denture when the dentures are five years of age.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of a replacement partial denture. have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a replacement partial denture.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a partial upper denture. 
 
You asked the Plan to pre-approve a partial upper denture. You say that this denture is medically necessary. 
The Plan denied your request. The Plan says that this denture is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically 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 a partial upper denture. Our physician reviewer found in this case  
a maxillary removable partial denture (D5213) to replace the missing teeth in the left quadrant meets the 
criteria for coverage as being medically necessary and reasonable to provide bilateral mastication and to 
prevent drifting and extrusion of teeth into the edentulous area. 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 partial upper 
denture have been met. Therefore, we decided that the Plan has to pre-approve a partial upper denture.  
 
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 nerve ablation procedure (64640). 
 
You asked the Plan to pre-approve the nerve ablation procedure. You say that the procedure is medically 
necessary. The Plan denied your request. The Plan says this procedure is considered experimental in this 
application. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the nerve ablation procedure. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found this procedure is still considered experimental / investigational and is the subject 
of on-going clinical trials. Therefore, the request is considered not medically reasonable or necessary. 
 
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 nerve ablation procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a nerve ablation procedure (64640).