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

 
We decided that the Plan does not have to pre-approve Gel-One injections (J7326). 
 
You asked the Plan to pre-approve Gel-One injections. You say that the injections are medically necessary. The 
Plan denied your request. The Plan says coverage criteria has not been met. 
 
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 Gel-One injections. Our reviewer says 
that the requested injections are not medically necessary. Our physician reviewer found based on the medical 
records provided there is no documentation that the Gel-One Injections are medically reasonable and necessary 
for the patient as there is no documentation of an adequate trial and failure of non-steroidal anti-inflammatory 
medication, other analgesics, physical therapy or a physician-directed home exercise program or weight loss. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gel-One injections have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Gel-One injections (J7326).
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a duplex scan of extremity veins (93971). 
 
You asked the Plan to pre-approve a duplex scan of extremity veins. You say that the services are necessary. 
The Plan denied your request. The Plan says that medical necessity has not been established. Therefore, 
coverage criteria has not been met. 
 
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 duplex scan of extremity veins. Our 
reviewer says that the requested items/services are considered medically reasonable and necessary in this case. 
Our physician reviewer found while the enrollee is clinically improved and the last scan of June 12, 2020 was 
negative it is reasonable to perform follow-up sonograms out to 1-year post ablation in order to evaluate for 
persistent superficial varicosities as well as recanalization of the ablated saphenous vein.  The exam is 
reasonable and should be approved. 
 
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 duplex scan of extremity veins have been met. Therefore, we decided that the 
Plan has to pre-approve a duplex scan of extremity veins (93971).  
 
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 pre-approve continued care with an out-of-network podiatrist. 
 
You asked the Plan to pre-approve podiatry care. You say that you have been seeing this doctor for years, and 
this doctor is currently treating an infection. The Plan denied your request. The Plan says the denial of 
authorization for this service is correct, because this provider is out-of-network with the Plan and you can be 
treated by an in-network podiatrist. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees needs. Your contract with the Plan says that, with few exceptions, you 
must use contract providers for care.  
 
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 podiatry care. Our reviewer says that 
you do not meet the Medicare criteria for continuity of care with the requested out-of-network podiatrist. Our 
physician reviewer found you are receiving periodic routine foot care, and your condition does not warrant 
continued care with an out-of-network provider. The Plan has shown that they have in-network podiatry 
specialists who have the qualifications and expertise necessary to meet the current medical standards of care 
required for your treatment. Your care can be safely transitioned to an in-network podiatry specialist 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 podiatry care have not been met. Therefore, we decided that the Plan does not 
have to pre-approve continued care with an out-of-network podiatrist.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve knee orthosis (L1851). 
 
You asked the Plan to pre-approve the knee orthosis. You say that the orthosis is medically necessary. The Plan 
denied your request. The Plan says the orthosis is not supported in the medical records received. 
 
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 knee orthosis. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the L1851 knee orthosis is not medically necessary as you have not had recent injury 
to or a surgical procedure on the knee(s). You are noted to be ambulatory and to have recently had a fall but the 
documentation does not specifically indicate this led to a right knee injury either by history or objective 
physical examination. The documentation does not reveal instability on an objective physical exam of the right 
knee. The documentation does not indicate the criteria per the LCD: Knee Orthoses (L33318) have been met. 
 
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 knee orthosis have not been met. Therefore, we decided that the Plan does 
not have to pre-approve knee orthosis (L1851).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power operated scooter. 
 
You asked the Plan to pre-approve the scooter. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not the most appropriate mobility device at this time. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 scooter. Our reviewer says that the 
requested scooter is not medically reasonable or necessary. Our physician reviewer found the documentation 
does not reveal a personal mobility deficit that impairs participation in MRADLs in the home. Your deficit is 
currently being helped by a walker if needed. You are independent without an assistive device, per the DME 
evaluation. 
 
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 scooter have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a power operated scooter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the E-Stick joystick attachment for the enrollee. 
 
You asked the Plan to pre-approve the attachment. You say that this is medically necessary. The Plan denied 
your request. The Plan says it would be unsafe for the enrollee to operate the wheelchair with the E-Stick. 
 
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 attachment. Our reviewer says that 
the requested attachment is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the requested E-Stick joystick attachment is not reasonable and necessary for the diagnosis or 
treatment of illness or injury or to improve the functioning of a malformed body member. The documentation 
does not support that the requested E-stick joystick device would be safe for the enrollee or the caregiver 
therefore the requested device is not medically 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 attachment have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the E-Stick joystick attachment for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Myoelectric Upper Extremity Orthotic device for the 
enrollee. 
 
You asked the Plan to pre-approve these services. You say that this will improve the enrollee's condition. The 
Plan denied your request. The Plan says that there is insufficient evidence that this will improve the enrollee's 
condition. 
 
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 these services. Our reviewer says that 
the requested Myoelectric Upper Extremity Orthotic device is not considered medically reasonable and 
necessary in this case. At this time the requested robotic orthosis is not proven to be more beneficial for 
treatment of the patient's medical condition/function of hemiparesis after stroke than any available standard 
therapy. The requested device is not reasonable and necessary for the diagnosis or treatment of an illness or 
injury or to improve the functioning of a malformed body member. Our physician reviewer found that the 
enrollee's condition does not meet Medicare criteria for these services. 
 
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 a Myoelectric Upper Extremity Orthotic device for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crowns (D2750) for tooth #'s 22 & 27. 
 
You asked the Plan to pre-approve the crowns. You say that you have less than 50% bone support to support 
the crowns. The Plan denied your request. The Plan says the service 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 crowns 
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 crowns. Our reviewer says that the 
crowns do not meet coverage criteria. Our physician reviewer found the criteria for coverage for crowns 
(D2750) for tooth #'s 22 and 27 have not been met due to the inadequate bone support and poor prognosis for 
retention. 
 
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 crowns have not been met. Therefore, we decided that the Plan does not 
have to pre-approve crowns (D2750) for tooth #'s 22 & 27.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for insertion of intrauterine device (IUD) services. 
 
You asked the Plan to pay for insertion of IUD. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the services received are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that items/services for the purposes of preventing 
conception (contraception) are not considered medically reasonable and necessary.  
 
Records show that the requested service is primarily for the purpose of contraception. The documentation does 
not show that this service is being requested to treat a specific illness/injury. As such, the Medicare rules for 
coverage of this item/service have not been met. Therefore, we decided that the Plan does not have to pay for 
insertion of intrauterine device (IUD).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for remote heart monitoring you received 
from your cardiologist on February 11, 2020 and May 12, 2020. 
 
You asked the Plan to waive the copayments for the remote heart monitoring with your cardiologist. You say 
that you will need this service every 90 days for the rest of your life, so you cannot afford these charges. The 
Plan denied your request. The Plan says you were charged these copayments correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment for specialist services.  
 
You have been asked to pay a $40 copayment for the remote heart monitoring with your cardiologist. 
According to your Evidence of Coverage, a specialist copayment also applies to this type of remote evaluation. 
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayments for remote heart monitoring you received from your 
cardiologist on February 11, 2020 and May 12, 2020.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for the abdominal x-ray (74019). 
 
You asked the Plan to pay for the x-ray. You say that you would like reconsideration because this service was 
denied as a duplicate in error. The Plan denied your request. The Plan says that CPT code 74019 is a column II 
procedure to 74022 which was billed and paid to another provider. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. MACs 
subject all line items for the same beneficiary, same NPI, and same date of service to NCCI edits.  
 
We find that CPT code 74019 is supported in the record. Specifically, CPT code 74019 was rendered by a 
provider with a separate NPI than who rendered the column I procedure. NCCI edits are not appropriate in this 
case. Based on this information, we decided that Medicare rules for coverage of the x-ray have been met. 
Therefore, we decided that the Plan has to pay for the abdominal x-ray (74019).  
 
 
 
 
 
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 unlisted procedure (00073) provided February 26, 2020. 
 
You asked the Plan to pay for the unlisted procedure. You say that before having the procedure you contacted 
the plan and was told that you would be responsible for the $40 copayment for specialist. You would like to be 
reimbursed the $150 that you paid out of pocket. The Plan denied your request. The Plan says this service was 
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. 
 
In this case, the CPT Code Manual definition of code 00073 is unlisted procedure. 
 
We find that CPT code 00073 is not supported in the medical record. Specifically, the provider must report the 
services with the appropriate CPT code. Based on this information, we decided that Medicare rules for 
coverage of the unlisted procedure have not been met. Therefore, we decided that the Plan does not have to pay 
for unlisted procedure (00073) provided February 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an extremity arterial study and computerized dynamic 
posturography testing. 
 
You asked the Plan to pay for diagnostic tests. You say that the provider deemed these services necessary for 
the enrollee's health. The Plan denied your request. The Plan says the denial of payment for these tests is 
correct. 
 
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 diagnostic tests. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found no procedure notes or test results were submitted for review. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of diagnostic tests have not been met. Therefore, we decided that the Plan does not 
have to pay for an extremity arterial study and computerized dynamic posturography testing.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on January 20, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for the home visit (99344), electrocardiogram (93000) and testing (87804). You say 
that you would like reconsideration because you provide urgent services in the home and prior authorization is 
not necessary. The Plan denied your request. The Plan says except for specific situations, services must be 
provided by contracted providers in order to be covered. 
 
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 medical services provided on January 20, 2020 
by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary, rest home visit. 
 
You asked the Plan to pay for the domiciliary, rest home visit. The Plan denied your request. The Plan says that 
the Plan requires utilization of network providers when possible and available, and requires authorization for 
certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency 
situation, has been documented. 
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for a domiciliary, rest home visit.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on June 4, 2020. 
 
You asked the Plan to pay for the electrocardiogram (93010). You say that you would like reconsideration 
because the services rendered were medically necessary. The Plan denied your request. The Plan says prior 
authorization is required and was not obtained. 
 
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 medical services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive genomic profile (CGP) testing. 
 
You asked the Plan to pay for genetic testing. You say that the enrollee's treating physician ordered this testing 
to determine if there was a more effective therapy for the enrollee's condition. The Plan denied your request. 
The Plan says the denial of payment for this testing is correct, because this testing was not billed with the 
appropriate coding. 
 
The Plan must follow Medicare rules. Medicare rules say that CGP testing must be billed with CPT code 81479.  
 
We looked at the file and Medicare rules. This testing was not billed with the appropriate coding. Based on this 
information, we decided that Medicare rules for coverage of genetic testing have not been met. Therefore, we 
decided that the Plan does not have to pay for comprehensive genomic profile (CGP) testing.