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

 
We decided that the Plan has to pay for a Zilretta injection rendered on September 14, 2022. 
 
You asked the Plan to pay for the injection. You say that this was medically necessary. The Plan denied your 
request. The Plan says that the clinical value and effectiveness of Zilretta in the setting of repeat administration 
(third treatment) for symptomatic osteoarthritis has not been demonstrated in the peer-reviewed literature. 
 
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 pay for the injection. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that Zilretta (triamcinolone acetonide extended-release injectable suspension) is indicated as an intra-
articular injection for the management of osteoarthritis pain of the knee. The documentation supports that 
Zilretta injections for both knees is medically reasonable and necessary for the patient and is safe and effective 
for the patient. 
 
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 injection have been met. Therefore, we decided that the Plan has to pay for a 
Zilretta injection rendered on September 14, 2022.  
 
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 anesthesia for procedures on lower posterior abdominal wall 
rendered on November 15, 2021. 
 
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 this is not necessary for treatment of the enrollee's condition. 
 
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 00820 is "Anesthesia for procedures on lower posterior 
abdominal wall." 
 
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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found that the billed anesthesia code - CPT 
00820 - was not appropriately billed. This is the incorrect CPT code, as this code does not describe 
sedation/anesthesia services for a sciatic nerve block. Monitored anesthesia codes are typically billed with CPT 
code 00100-01999, a specific anesthesia service for a diagnostic or therapeutic procedure. Although this 
enrollee received Midazolam 2mg IV for conscious sedation by a certified registered nurse anesthetist (CRNA) 
for the sciatic nerve block, medical necessity for an anesthesia provider to administer monitored anesthesia care 
(MAC) was also not established. The enrollee was documented as American Society of Anesthesiologists 
(ASA) 3, however, there was no medical necessity documented to require an anesthesia provider to be present 
for the enrollee's procedure. Of note, it is unclear of how the submitted bill/billed units were arrived at for the 
10-minute billing time/procedure. 
 
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 not been met. Therefore, we decided that the Plan does not 
have to pay for anesthesia for procedures on lower posterior abdominal wall rendered on November 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulation (TENS) 
supplies billed with code E0730 for October 28, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says there is no valid proof of delivery. 
 
The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules say that all DMEPOS 
suppliers are required to maintain proof of delivery. 
 
We looked at the file and Medicare rules. There is no valid proof of delivery in the documentation. Based on 
this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, 
we decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulation (TENS) 
supplies billed with code E0730 for October 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the SelectMDx test (0339U) provided on October 24, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory service. You say that you are requesting the claim be reconsidered 
for payment. The test was ordered by the enrollee's treating physician. 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 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 had network providers 
available who could have provided 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 SelectMDx test (0339U) provided on October 
24, 2022, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Korsuva. 
 
You asked the Plan to pre-approve Korsuva. You say that the services are necessary. The Plan denied your 
request. The Plan says the requested drug is covered through the dialysis provider. Therefore, coverage criteria 
has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that the End Stage Renal Disease (ESRD) 
Prospective Payment System (PPS) functional category is a distinct grouping of drugs and biologicals, as 
determined by Centers for Medicare & Medicaid Services (CMS), whose end action effect is the treatment or 
management of a condition or conditions associated with ESRD. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of Korsuva have not been met. Therefore, we decided that the Plan does not have to pre-approve 
Korsuva.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve artificial discs for the neck at four levels. 
 
You asked the Plan to pre-approve artificial discs at four levels. You say that the services are necessary. The 
Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria have not been met. 
 
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 artificial discs at four levels. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found 4 level cervical artificial disc surgery is experimental. It is only FDA 
approved for single level use. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of artificial discs at four levels have not been met. Therefore, we decided that the 
Plan does not have to pre-approve artificial discs for the neck at four levels.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supplies billed with 
code K0553 for April 1, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says there is no valid proof of delivery. 
 
The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules say that all DMEPOS 
suppliers are required to maintain proof of delivery. 
 
We looked at the file and Medicare rules. There is no valid proof of delivery in the documentation. Based on 
this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, 
we decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supplies billed with 
code K0553 for April 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an oral appliance (E0486) provided on June 1, 2022. 
 
You asked the Plan to pay for an oral appliance. You say that you were advised by the Plan's customer service 
representatives that the item at issue would be covered. The Plan denied your request. The Plan says rules for 
payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of an oral appliance have been met. 
Specifically, no medical documentation has been provided to support the medical necessity of the oral appliance in this case. Therefore, we decided that the Plan does not have to pay for an oral appliance (E0486) 
provided on June 1, 2022.  
 
Your complaint about receiving erroneous or incomplete information about your benefits from representatives 
of the Plan 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory test (81518) provided on August 17, 2022. 
 
You asked the Plan to pay for the laboratory test. You say that this test was medically necessary and is 
supported in the medical record. The Plan denied your request. The Plan says the claim for this molecular 
pathology testing did not include the required unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the laboratory test 
have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory test (81518) 
provided on August 17, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heavy-duty hospital bed. 
 
You asked the Plan to pre-approve a heavy-duty hospital bed. You say that you are bedridden and need to be 
able to turn over so that your nurses can service and change you.  You stated that your current bed is too 
narrow to do these turns. The Plan denied your request. The Plan says you do not meet Medicare criteria for 
coverage of a heavy-duty hospital bed. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare only covers heavy-duty hospital beds 
for patients weighing between 350 and 600 pounds. Your most recent medical records state that you weigh 300 
pounds, so you do not meet the weight criteria for this item. We looked at the file and Medicare rules. Based on 
this information, we decided that Medicare rules for coverage of a heavy-duty hospital bed have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a heavy-duty hospital bed.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on October 31, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were rendered by an out-of-network provider without prior authorization. 
 
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 had network providers 
available who could have provided 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 provided on October 31, 2022, by 
an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on September 2, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services were necessary and are supported in 
the medical record. The Plan denied your request. The Plan says you billed with an incorrect place of service 
on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on September 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99239 billed for date of service November 18, 2022. 
 
You asked the Plan to pay for code 99239. You say that you believe this claim was billed correctly. The Plan 
denied your request. The Plan says this service was not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must bill the correct POS code on the 
claim.  In this case, you billed the services in dispute with POS code 21, indicating that the services occurred in 
an inpatient hospital setting.  However, this patient was not an inpatient.  Rather, the patient was kept in 
observation, which is an outpatient hospital setting.  As a result, POS code 22 should have been entered on the 
claim, or another code should have been billed. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 99239 have not been met. Therefore, we decided that the Plan does not have to pay for code 
99239 billed for date of service November 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the miscellaneous vision item provided on November 24, 
2022.  
You asked the Plan to pay for the miscellaneous vision item. You say that you are appealing the denial. The 
Plan denied your request. The Plan says the item is not a covered benefit. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan does not cover this item. 
 
We looked at the file and the Plan's rules. Specifically, the service is not a covered benefit. Based on this 
information, we decided that the Plan's rules for coverage of the miscellaneous vision item have not been met. 
Therefore, we decided that the Plan does not have to pay for the miscellaneous vision item provided on 
November 24, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Kerendia. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says self-administered drugs are not covered. 
 
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 Kerendia.   
Benefits for these services 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for domiciliary or rest home visit provided on August 05, 2022. 
 
You asked the Plan to pay for domiciliary or rest home visit. You say that the records attached support the 
services provided. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for domiciliary or rest home 
visit provided on August 05, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a consultation (D9310) provided on November 2, 2022. 
 
You asked the Plan to pay for the dental service. You say that you would like the Plan to pay for the dental 
services because you cannot afford it. The Plan denied your request. The Plan says the denial of payment for 
this service is correct, because the consultation is not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a 
consultation (D9310) provided on November 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core buildup (D2950) for tooth #31. 
 
You asked the Plan to pre-approve the dental services. You say that you dentist sent in a treatment plan and the 
Plan was not going to pay anything. The Plan denied your request. The Plan says your annual maximum dental 
benefit for the year has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows the Plan pre-approved a crown (D2740) for tooth #31 in the amount of $1,000; therefore, your annual 
maximum dental benefit for the year of 2023 was exhausted on the date of approval of February 21, 2023. 
Therefore, we decided that the Plan does not have to pre-approve core buildup (D2950) for tooth #31.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room visit provided on 
September 21, 2022. 
 
You asked the Plan to waive the copayment for the emergency room visit. You say that you only went to the 
emergency room on the advice of your cardiologist and did not feel you needed to go. The Plan denied your 
request. The Plan says this cost sharing was charged 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 $90 
copayment for emergency care. 
 
You have been asked to pay a $90 copayment for the emergency room visit. This item/service falls within the 
emergency care 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 the emergency room visit 
provided on September 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 Reader Device. 
 
You asked the Plan to pre-approve the Freestyle Libre 2 Reader Device. You say that the enrollee needs 
continuous monitoring. The Plan denied your request. The Plan says the enrollee does not require insulin three 
or more times daily. 
 
 
  
 
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 2 Reader Device have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a Freestyle Libre 2 Reader Device.