Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve parenteral nutrition solution (CPT code(s): B4185, 
B4189, B4193, B4197, B4199, B4224). 
 
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says enteral nutrition is only covered when the enrollee is fed through a tube into 
the stomach or small intestine and the condition that requires the tube feeding must be considered permanent. 
The Plan states it appears that the enrollee is able to eat and drink with their mouth and the enrollee does not 
have a permanent feeding tube, so the Plan is not able to approve this per Medicare rules. 
 
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 service. Our physician reviewer 
found per Medicare rules, enteral nutrition is only covered when you are fed through a tube into the stomach or 
small intestine and the condition that requires the tube feeding must be considered permanent. It appears that 
the enrollee is able to eat and drink with their mouth and does not have a permanent feeding tube. The review 
has determined that the medical records provided do not meet the requirements listed in the LCD for Medicare 
coverage. 
 
 
 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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve parenteral nutrition solution (CPT code(s): B4185, B4189, B4193, B4197, B4199, B4224).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve block with fluoroscopy. 
 
You asked the Plan to pre-approve a genicular nerve block with fluoroscopy. 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 a genicular nerve block with 
fluoroscopy. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found this is considered an experimental/investigational 
procedure whose role in the management of knee pain has not been fully demonstrated. 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 a genicular nerve block with fluoroscopy have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a genicular nerve block with fluoroscopy.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve arthrocentesis, aspiration and/or injection, major joint or 
bursa (eg, shoulder, hip, knee, subacromial bursa); with ultrasound guidance, with permanent recording and 
reporting (CPT code 20611) and Euflexxa Soln Pref Syr 20MG/2ML (CPT code J7323). 
 
You asked the Plan to pre-approve the services. You say that the medication is necessary. The Plan denied your 
request. The Plan says when there was no improvement in knee pain and functional improvement from a 
previous series of injections, a repeat series of injections will be considered not reasonable and necessary and 
will not be covered. 
 
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 the services. Our physician reviewer 
found the record indicates that you have osteoarthritis of the knee. The Food and Drug Administration (FDA) 
has stated that the requested drug is indicated for your condition. The record indicates that you completed a 
series of Orthovisc injections less than six (6) months ago in November 2021, that did not provide documented 
benefit. The record provided does not establish the medical necessity and reasonableness, as defined by 
Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied. The requested 
service is not 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, 
subacromial bursa); with ultrasound guidance, with permanent recording and reporting (CPT code 20611) and 
Euflexxa Soln Pref Syr 20MG/2ML (CPT code J7323).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on June 17, 
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 the denied codes remain not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that 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 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 laboratory services provided to the enrollee on June 17, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Modafinil. 
 
You asked the Plan to pre-approve Modafinil. You say that the medication is necessary. The Plan denied your 
request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
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 Modafinil.  
 
Benefits for Modafinil 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Superion interspinous spacer. 
 
You asked the Plan to pre-approve a Superion interspinous spacer. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has 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 a Superion interspinous spacer. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the superion spacer is experimental. More research is needed to show 
safety and efficacy. 
 
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 Superion interspinous spacer have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a Superion interspinous spacer.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (36000) provided September 23, 2021. 
 
You asked the Plan to pay for the surgical services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says coverage criteria has not been met. 
 
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 code 36000 has a status indicator of B on the Physician Fee Schedule. This means that CPT code 36000 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of the surgical services have not been met. Therefore, we decided that the Plan does not have to pay for 
surgical services (36000) provided September 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the left wrist/hand orthosis (L3916) provided on September 
8, 2021. 
 
You asked the Plan to pay for the left wrist/hand orthosis (L3916). You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid physician order for the supplies provided in this case. The record shows 
that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the left wrist/hand orthosis (L3916) provided on September 8, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by a contracted provider on October 
7, 2021, to November 11, 2021. 
 
You asked the Plan to pay for dental services. You say that you would like this reprocessed and paid. The Plan 
denied your request. The Plan says the annual maximum allowance amount of $1,800 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. The Plan covers dental 
services up to an $1,800 annual benefit allowance maximum.   
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of dental services have already been met. Therefore, we decided that the Plan does not have to pay for 
dental services provided by a contracted provided on October 7, 2021, to November 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to adjust the copayments for the subcutaneous tissue debridement 
(11042) provided from June 30, 2021, through August 18, 2021. 
 
You asked the Plan to adjust the copayments. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayments have been applied correctly to 
the services provided. 
 
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 $325 
copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital, including 
but not limited to hospital or other facility charges and physician or surgical charges.    
You have been asked to pay $2,275 ($325 copayment x 7) for the Medicare-covered outpatient surgery services 
provided on June 30, 2021, July 7, 2021, July 14, 2021, July 28, 2021, August 4, 2021, August 11, 2021, and 
August 18, 2021. 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 adjust the copayments for the subcutaneous tissue 
debridement (11042) provided from June 30, 2021, through August 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve six (6) office consultations and treatments (CPT code 
99214) to be provided by an out-of-network provider. 
 
You asked the Plan to pre-approve the out-of-network services. You say that the services are necessary. The 
Plan denied your request. The Plan says you would be able to see a network provider for this service. 
 
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 
six (6) office consultations and treatments (CPT code 99214) to be provided by an out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for neuromonitoring services (G0453) provided November 16, 
2021. 
 
You asked the Plan to pay for the neuromonitoring services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says the claim was not billed with a valid diagnosis code. 
 
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 code G0453 is not supported in the medical record. Specifically, per Local Coverage Article 
A56722: Intraoperative Neurophysiological Testing, E21.3 is not a covered diagnosis code. Based on this 
information, we decided that Medicare rules for coverage of the neuromonitoring services have not been met. 
Therefore, we decided that the Plan does not have to pay for neuromonitoring services (G0453) provided 
November 16, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation. 
 
You asked the Plan to pre-approve additional routine transportation. You say that the services are necessary. 
The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not 
been met. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 48 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric services. 
 
You asked the Plan to pre-approve inpatient psychiatric services. You say that the records provided support the 
need for continued inpatient psychiatric care. The Plan denied your request. The Plan says the enrollee has 
reached reasonable expectations for improvement and is medically stable. The Plan says that the enrollee has 
no acute symptoms that require 24-hour inpatient care. The Plan says that continued inpatient psychiatric care 
is not medically necessary. 
 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.   
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 inpatient psychiatric services. Our 
reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee was 
involuntarily admitted to the acute inpatient psychiatric hospitalization on March 25, 2022, with 
Schizoaffective Disorder, Bipolar Type. Based upon review the records provided it was not expected this 
enrollee would improve in a reasonable period of time for the dates in question as she did not have suicidal or 
homicidal ideation, auditory or visual hallucinations. The enrollee was compliant with treatment while not 
showing any acute threats to safety. It did not appear medically necessary and reasonable to have psychiatric 
care provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question 
as she did not have dangerousness to self or others and was compliant with her treatment. It did not appear that 
the services were reasonably expected to improve the patients condition or for the purpose of diagnosis 
beyond the date in question. The enrollee was cooperative/compliant with treatment while not showing any 
threats to safety. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve inpatient psychiatric services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for colonoscopy services provided to the enrollee on May 12, 
2021. 
 
You asked the Plan to pay for the services. You say that these services are supported in the record and these 
services were for two polyps in separate areas. The Plan denied your request. The Plan says the denied codes 
remain not supported. 
 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 the denied codes is: 
 
CPT 45385: 
 
colonoscopy with lesion removal 
 
CPT 45390: 
 
colonoscopy with endoscopic mucosal resection 
 
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 after a careful review of all medical 
records submitted on pages 23-30, 65-72, no procedure report was found. It is unable to be determined if the 
procedures were on two separate lesions. Therefore this service cannot be verified. 
 
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 colonoscopy services provided to the enrollee on May 12, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied 
your request. The Plan says transfer to a SNF for inpatient skilled rehabilitation services is not medically 
necessary. 
 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 the admission. Our reviewer says that 
the requested admission is not medically reasonable or necessary. Our physician reviewer found the enrollee 
has stabilized medically and has been receiving skilled rehab services in an inpatient rehabilitation facility 
(IRF). The enrollee has tolerated inpatient rehab services and continues to improve with daily skilled nursing 
and/or skilled therapy services.  He could benefit from continued services at the current level of care. The 
enrollee has made slow progress with therapy, there is no indication that transfer to a skilled nursing facility is 
required. He can continue to receive skilled rehab services at the current IRF or be stepped down to a lower 
level of care when appropriate. There are no services offered at a SNF that are not offered at an inpatient rehab 
facility. Admission to a SNF for inpatient skilled rehab services 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 admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Cyclobenzapr 10MG tablet. 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says Cyclobenzaprine is a self-administered drug and does not fall under Part B 
coverage. 
 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 Cyclobenzapr 10MG tablet.  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.