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

 
We decided that the Plan does not have to pre-approve Zilretta. 
 
You asked the Plan to pre-approve Zilretta. You say that the requested Zilretta is medically necessary. The Plan 
denied your request. The Plan says the requested Zilretta is 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 Zilretta. Our reviewer says that the 
requested Zilretta is not medically necessary. Our physician reviewer found the record indicates that the 
enrollee has a diagnosis of osteoarthritis of the knee. The requested drug is being used for its current Food and 
Drug labelled indication. The Food and Drug Administration has not restricted its use to a single time. The 
medical records provided are insufficient to determine the medical necessity of the requested service at this 
time as they are over eight months old and do not address the requested use. The elements of the coverage 
criteria are not satisfied. The requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Zilretta have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Zilretta.
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 enrollee has great potential to get back to a 
previous baseline with rehabilitation. The Plan denied your request. The Plan says the denial of authorization 
for IRF care is correct. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 and does not need rehabilitation physician 
supervision 3 times per week. The enrollee does not need intensive therapies consisting of at least 3 hours of 
therapy per day for at least 5 days per week with a multidisciplinary approach to rehabilitation care. The 
enrollee's rehabilitation can be safely provided in a lower intensity setting such as 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve an office visit. You say that this would be a follow up visit to make sure you 
can travel back to your home state. The Plan denied your request. The Plan says the enrollee must receive their 
care from a 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 provider at issue in this case is not a network provider with the Plan. 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 office visit. Our reviewer says that this does not meet criteria. Our physician reviewer found at issue is the medical necessity of having the patient referred to an out-of-network 
provider for an office visit, and there are credentialed, experienced physicians within the patient's network who 
could be utilized for the patient's clinical condition. Our doctor also found that there is insufficient 
documentation to support the medical necessity for referral to an out-of-network provider for the patient's 
office visit. 
 
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 office visit have not been met.  
 
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 an office visit. Therefore, we decided that the Plan 
does not have to pre-approve an office visit to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the needle electromyography (95886), nerve conduction 
studies (95909), and digital analysis of EEG (95957) provided on April 26, 2021. 
 
You asked the Plan to pay for the needle electromyography (95886), nerve conduction studies (95909), and 
digital analysis of EEG (95957). You say that the claim for the service codes were billed correctly and the CPT 
codes utilized are correct for the type of service performed. The Plan denied your request. The Plan says 
procedure codes 95886, 95909 and 95957 are not supported in the documentation therefore they 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 95886 is needle electromyography, each extremity, with 
related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; 
complete, five or more muscles studied, innervated by three or more nerves or four or more spinal levels (List 
separately in addition to code for primary procedure). The CPT Code Manual definition of code 95909 is nerve 
conduction studies; 5-6 studies. The CPT Code Manual definition of code 95957 is digital analysis of 
electroencephalogram (EEG) (eg, for epileptic spike analysis). 
 
We asked our coder 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 needle electromyography (95886), nerve conduction 
studies (95909), and digital analysis of electroencephalogram (EEG) (95957). Our reviewer says that procedure 
codes 95886, 95909 and 95957 are not supported by the medical records. Our reviewer found that the technical 
report did not include documentation of a complete needle electromyography; therefore, CPT code 95886 
cannot be verified. The technical report also did not include documentation of nerve conduction studies, for 5-6 
studies; therefore, CPT code 95909 cannot be verified. Real time EEG monitoring was done which is not 
covered by this code. Per CPT assistant, a more specific CPT code exists for establishing an EEG baseline. 
Additional EEG monitoring, reflected by CPT code 95957, would be included in the intraoperative 
neuromonitoring code. 
 
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 needle electromyography (95886), nerve conduction studies (95909), and 
digital analysis of EEG (95957) have not been met. Therefore, we decided that the Plan does not have to pay 
for the needle electromyography (95886), nerve conduction studies (95909), and digital analysis of EEG 
(95957) provided on April 26, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient services provided from May 14, 2021, through 
May 17, 2021. 
 
You asked the Plan to pay for the inpatient services. You say that the diagnosis code is supported by the 
physician's documentation and the information contained in the patient's medical record. You say that you 
disagree with the DRG reassignment, and the original determination should be overturned. The Plan denied 
your request. The Plan says the diagnosis code for Acute and chronic respiratory failure, unspecified whether 
with hypoxia or hypercapnia, is not supported by the hospital record. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services with secondary diagnosis code J96.20, defined as acute and 
chronic respiratory failure, unspecified. 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 the 
inpatient services. Our reviewer says that the documentation does not support the secondary diagnosis code of 
J96.20. Our physician reviewer found that the enrollee was admitted for the management of multifocal 
pneumonia, receiving intravenous antibiotics and was managed on room air. There was no documentation of 
acute or chronic respiratory failure.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for the inpatient services provided from May 14, 2021, through May 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit (99214) provided on 
October 6, 2021. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that the first time you went, 
you asked if there was a copayment, and nobody said anything. The Plan denied your request. The Plan says 
you were charged the correct copayment amount. 
 
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 Medicare-covered specialist visit.  
 You have been asked to pay a $40 copayment for a specialist office visit. A specialist office visit falls within 
the physician/practitioner services, including doctors office visits benefit category. 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 copayment for a specialist office visit (99214) provided on October 6, 2021  
 
Your complaint about potentially being billed for services you have already paid is not a valid appeal for 
medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does 
not permit us to make a decision about these types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the FreeStyle Libre Continuous Glucose Monitor 
(CGM). 
 
You asked the Plan to pre-approve the FreeStyle Libre CGM. You say that you would like reconsideration 
because the enrollee cannot see well enough to check their blood sugar levels. The Plan denied your request. 
The Plan says the enrollee does not meet criteria for the requested CGM. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of 
the FreeStyle Libre CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve 
the FreeStyle Libre Continuous Glucose Monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractor services (97014 and 98941) provided from 
June 30, 2021, to July 19, 2021. 
 
You asked the Plan to pay for codes 97014 and 98941. You say that you would like the Plan to reconsider your 
request. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation. However, the Plan offers a chiropractic benefit that 
exceeds Medicare coverage. For that reason, the Plans coverage rules also apply in this case. 
 
The records show that code 97014 is not manual manipulation of the spine. Though the Plan offers a 
chiropractic benefit in excess of Medicare coverage, code 97014 is not among those covered under this benefit. 
 
The rules also say that providers must report services correctly. A chiropractor must place an AT modifier on a 
claim when providing active/corrective treatment to treat acute or chronic subluxation. In this case, the 
contracted provider did not bill code 98941 with the appropriate AT modifier. Please note, per Medicare 
criteria, when a contracted provider furnishes a service that you reasonably believe is a plan-covered service, 
you cannot be financially liable for more than the applicable cost-sharing for that service. In this case, your 
copayment for code 98941 would be $0 per your contract with the Plan. You cannot be charged more than $0 
for the billing of code 98941. 
 
Therefore, we decided that the Plan does not have to pay for the chiropractor services (97014 and 98941) 
provided from June 30, 2021, to July 19, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cervical lymphadenectomy provided on September 22, 2021. 
 
You asked the Plan to pay for cervical lymphadenectomy. You say that the record supports this coding. The 
Plan denied your request. The Plan says the denial of payment for this service is correct, because the records do 
not support the code billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 38720 is cervical lymphadenectomy (complete). 
 
We asked our coder 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 cervical lymphadenectomy. Our reviewer says that code 
38720 does not meet the criteria for payment. Our reviewer found the operative report does not document a 
complete lymphadenectomy to include lymph tissue, blood vessels, nerves, and muscles per the coding policy 
manual.  
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of cervical lymphadenectomy have not been met. Therefore, we decided that the 
Plan does not have to pay for cervical lymphadenectomy provided on September 22, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (83789) provided on August 18, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled 
service.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 83789 
is a column II code to column I code 80307. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for the services (83789) provided on August 18, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (70450) provided on December 9, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled 
service. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for the services (70450) provided on December 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injection of anesthetic agent (64415) provided on 
November 15, 2021. 
 
You asked the Plan to pay for the injection of anesthetic agent. You say that this claim is eligible for payment 
as billed. The Plan denied your request. The Plan says this claim has not been billed as required by Medicare 
coding regulations. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 64415 
is a column II code to column I code 00400. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for the injection of anesthetic agent (64415) provided on November 
15, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eliquis. 
 
You asked the Plan to pre-approve Eliquis. You say that the enrollee needs this drug. The Plan denied your 
request. 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 also says the requested drug is not 
covered 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 Eliquis.  
 Benefits for Eliquis 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee needs further care at the SNF to regain 
maximum function. The Plan denied your request. The Plan says the denial of authorization for SNF care is 
correct. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the enrollee does not have daily skilled 
nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The 
enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment 
of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on 
an inpatient basis in a skilled nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for batteries provided on May 25, 2021, and August 30, 2021. 
 
You asked the Plan to pay for batteries. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says batteries are not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pay for batteries provided on May 25, 2021, and August 30, 2021.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Botox injections (J0585) and administration of (64644, 64645, 
64646). 
 
You asked the Plan to pre-approve the Botox injections. You say that the requested injections are necessary. 
The Plan denied your request. The Plan says that the coverage criteria have 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 the Botox injections. Our reviewer says 
that the requested Botox injections are considered medically reasonable and necessary in this case. Our 
physician reviewer found the provided documentation indicates that the requested Botox injections are 
medically reasonable and necessary. The reviewer also found that the criteria 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 Botox injections have been met. Therefore, we decided that the Plan has to 
pre-approve Botox injections (J0585) and administration of (64644, 64645, 64646).  
 
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.