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

 
We decided that the Plan does not have to pre-approve Ilumya. 
 
You asked the Plan to pre-approve Ilumya. The Plan denied your request. The Plan says the step therapy 
criteria are not met. 
 
 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Ilumya. Our reviewer says that Ilumya 
is not medically reasonable and necessary in this case. Our physician reviewer found that the record indicates 
that the enrollee has psoriasis vulgaris. The requested medication is a new start. The provided records do not 
indicate that the enrollee has tried and failed the Plan's preferred step one alternatives. The record does not 
indicate that the enrollee has a contraindication to or would have an adverse effect from the Plan's preferred 
step one alternatives. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Ilumya have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Ilumya.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro Motion G orthotic device (L8702). 
 
You asked the Plan to pre-approve the orthotic device. You say that the MyoPro is supported as an appropriate 
intervention and is reasonably and medically necessary as recognized by medical communities and key opinion 
leaders in rehabilitation. The Plan denied your request. The Plan says this item is considered experimental and 
investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered. 
 
We looked at the file, and Medicare rules. There is insufficient evidence of its effectiveness in those with 
stroke and hemiparesis. Based on this information, we decided that Medicare rules for coverage of the orthotic 
device have not been met. Therefore, we decided that the Plan does not have to pre-approve the MyoPro 
Motion G orthotic device (L8702).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation services provided 
on September 19, 2021. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that you feel that you 
should not have two copayments for the ambulance trips. The Plan denied your request. The Plan says you 
have been charged the correct cost sharing 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 $180 
copayment per date of service regardless of the number of trips.  
 You have been asked to pay a $180 copayment for the ambulance transportation. Please note that only one 
copayment was applied for both trips. The ambulance transportation falls within the Ambulance Services 
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 ambulance transportation 
services provided on September 19, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an electrocardiogram (ECG) provided on 
October 20, 2021. 
 
You asked the Plan to waive the copayment for the ECG. You say that the service should be included with the 
annual physical exam. The Plan denied your request. The Plan says you have been charged the correct cost 
sharing 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 $0 copayment for an annual physical. If you receive services that address a medical condition during the same 
visit, additional cost sharing may apply. 
 
Your contract with the Plan also clearly says that you must pay a $10 copayment for outpatient diagnostic tests, 
including ECG's. 
 
The file shows that while you were seen for an annual exam, you also had the ECG performed, which goes 
beyond the scope of a routine annual exam. Therefore, you have been asked to pay a $10 copayment for the 
ECG. The ECG falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies 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 an electrocardiogram (ECG) provided on 
October 20, 2021.
Appeal type: Imaging
Decision: Partially Favorable

 
We decided that the Plan has to reduce the copayment for an external electrocardiographic recording. We 
decided that the Plan does not have to reduce the copayment for an external electrocardiographic recording to 
the amount you requested.   
 
You asked the Plan to waive the copayment for an external electrocardiographic recording. You say that you 
already paid the $45 copayment and disagree with the charges. The Plan says that the claims were processed 
correctly and you are being charged the correct amount. 
 We decided that the Plan has to reduce the copayment for an external electrocardiographic recording 
from $45 to $10.   
 
Your contract with the Plan says that you must pay $10 copayment for outpatient procedures and tests, 
including ultrasounds at all locations of service.  
 
The Plan says that you must pay $45 for an external electrocardiographic recording. However, you cannot be 
asked to pay more than a $10 copayment for outpatient diagnostic tests. Therefore, we decided that the Plan has 
to reduce the copayment for an external electrocardiographic recording from $45 to $10.  
 
We also decided that the Plan does not have to waive the copayment for an external electrocardiographic 
recording. 
 
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 $10 
copayment for diagnostic procedures and tests, including ultrasounds at all locations of service. Therefore, we 
decided that the Plan does not have to waive the $10 copayment for an external electrocardiographic recording. 
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve aquatic therapy to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the aquatic therapy. You say that you need to do aquatic therapy to get your 
legs stronger so you can have surgery. You also say that if you do not get stronger, you will not be able to get 
surgery and will be in a wheelchair for the rest of your life. The Plan denied your request. The Plan says the 
medical care you require can be provided by a network provider. The Plan also says that your medical group 
has agreed to send you for an evaluation to one of their network providers who can perform aquatic therapy. 
 
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 
aquatic therapy to be provided by an out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a psychiatry follow up to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve a psychiatry follow up. You say that the in-network provider that you saw is 
not giving you the proper treatment you need. The Plan denied your request. The Plan says an appointment has 
been made with another in-network provider that provides the same quality of care as the out-of-network 
provider does. 
 
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 
a psychiatry follow up to be provided by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on August 3, 
2021. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you are being balance billed. 
The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the 
correct 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 $330 
copayment for ambulance services.  
 
You have been asked to pay the allowed amount of $321.59, which is less than the $330 copayment for 
ambulance services. Ambulance services fall within the ambulance services 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 ambulance services provided on August 3, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ten (10) additional speech therapy (ST) visits (92507). 
 
You asked the Plan to pre-approve additional ST visits. You say that the requested additional ST visits are 
medically necessary. The Plan denied your request. The Plan says the requested additional ST visits do not 
meet criteria. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
 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 additional ST visits. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the enrollee has had 10 ST sessions approved and the documentation 
does not reveal the outcome of the completed 10 ST sessions to determine if the enrollee requires 10 more ST 
sessions with the unique skills of a professional therapist to safely and effectively provide treatment. Without 
completion of the already approved therapy, it is not clear that ongoing services can be safely and effectively 
performed only by a therapist, or by or under the supervision of a therapist. The requested services are not part 
of a maintenance program and the specialized skill, knowledge and judgment of a qualified therapist is not 
required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent 
or slow further deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional ST visits have not been met. Therefore, we decided that the Plan does 
not have to pre-approve ten (10) additional speech therapy (ST) visits (92507).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the patient's pain is disabling, has been 
of long-term duration and has failed non-operative treatment. You say that the evidence clearly supports the use 
of the Intracept procedure as the primary treatment for chronic low back pain the denial should be overturned. 
The Plan denied your request. The Plan says the service is considered not reasonable and necessary. 
 
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 Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there are limited large-scale, long-term references showing the safety and 
efficacy of the requested surgery in this clinical setting. There is no compelling rationale presented or 
extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. 
Therefore, the request for Intracept procedure at L4, L5, and S1 is not medically reasonable or necessary. 
 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the interpretation of a computed tomography (CT) scan of 
the head provided on September 15, 2021, billed with code 70450-26-77. 
 You asked the Plan to pay for the CT interpretation as billed. You say that this should be paid as the enrollee 
had multiple imaging tests performed on this date. The Plan denied your request. The Plan says this code is a 
Column 2 code without an appropriate NCCI modifier. Modifier -77 does not allow for bypass of NCCI edits. 
 
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 which was reported by the same billing provider on this date of 
service.  
 
Though modifier -77 is used, this would be to differentiate between this service and another claim for the same 
service, not to bypass the edit with 70496. 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 interpretation of a computed 
tomography (CT) scan of the head provided on September 15, 2021, billed with code 70450-26-77.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve trigger point injections (TPIs). 
 
You asked the Plan to pre-approve the requested TPIs. You say that it is felt that these injections can help to 
reduce pain. The Plan denied your request. The Plan says the documentation does not support this treatment is 
necessary at this time. 
 
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 requested TPIs. Our reviewer says 
that the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee is a 54-year-old male with a history of spina bifida and a tethered cord.  The 
enrollee has ongoing low back and neck pain thought to be due to facet arthropathy and sacroiliitis.  He has 
been treated with medical therapy including opiates, has had cervical diagnostic medical branch blocks, 
sacroiliac joint injections, and a lumbar radiofrequency ablation. He had lumbar trigger point injections 
performed on 11/18/2021. His provider has requested additional lumbar trigger point injections. 
 
 The treatment of myofascial pain is to utilize multi-disciplinary approach with a combination of medications, 
non- pharmacological approaches and trigger point injection techniques. In this case, there is no documentation 
of lumbar trigger points on palpation on physical exam.  The review has determined that the items/services at 
issue in this case are not medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested TPIs have not been met. Therefore, we decided that the Plan does 
not have to pre-approve trigger point injections (TPIs).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and segmental 
pneumatic appliance (E0667). 
 
You asked the Plan to pre-approve a pneumatic compression device and appliance. You say that please reverse 
the denial as the attached documentation speaks to her clinical presentation, failure of conservative treatments 
and the need for advanced pneumatic compression. The Plan denied your request. The Plan says the enrollee 
does not meet the LCD criteria for an advanced lymphedema pump as there is no failed four-week trial of a 
basic pneumatic compression device of either E0650 or E0651. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652) and segmental pneumatic appliance (E0667).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (K0554) and related 
supplies (K0553). 
 
You asked the Plan to pre-approve a continuous glucose monitor and related supplies. You say that the 
requested items are a necessity for your care. The Plan denied your request. The Plan says rules for coverage 
for a continuous glucose monitor and related supplies have not been met. 
 
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 you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of a continuous 
glucose monitor and related supplies have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a continuous glucose monitor (K0554) and related supplies (K0553).
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve L5-S1 anterior lumbar discectomy and arthroplasty. 
 
You asked the Plan to pre-approve the L5-S1 anterior lumbar discectomy and arthroplasty. You say that you 
would like reconsideration because the requested procedure is medically necessary. The Plan denied your 
request. The Plan says that there are not enough studies to show that this procedure works well for the 
member's condition. 
 
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 L5-S1 anterior lumbar discectomy 
and arthroplasty. Our reviewer says that the requested items/services are considered medically reasonable and 
necessary in this case.  The magnetic resonance imaging of the lumbar spine has findings of trace 
anterolisthesis of L5 on S1; L5-S1: facet arthropathy and diffuse disc bulge with superimposed central disc 
protrusion causing mild bilateral neural foraminal narrowing without significant spinal canal stenosis. Our 
physician reviewer found provided documentation demonstrates subjective and objective deficits that are 
corroborated by imaging studies. Trial and failure of conservative treatment modalities has been documented. 
 
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 L5-S1 anterior lumbar discectomy and arthroplasty have been met. 
Therefore, we decided that the Plan has to pre-approve L5-S1 anterior lumbar discectomy and arthroplasty.  
 
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.