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

 
We decided that the Plan does not have to pre-approve Euflexxa (J7323). 
 
You asked the Plan to pre-approve Euflexxa. You say that the injections are medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Euflexxa. Our reviewer says that the 
injections are not medically necessary. Our physician reviewer found inadequate time has elapsed between the 
date of the corticosteroid injection and the request for the Euflexxa. The health plan requires two months time 
after the corticosteroid joint injection to evaluate response, this two month time period is consistent with the 
pharmacokinetics of an intraarticular injection and with Medicare guidelines. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa (J7323).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a non-powered mattress overlay provided at in-network 
benefit level to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a non-powered mattress overlay provided at in-network benefit level. You 
say that you would like this covered at the in-network level. The Plan denied your request. The Plan says that 
these services are available 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 if you use an out-of-network provider, your share of the costs for your covered services may be 
higher. 
 
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 services at an in-network level of care. Therefore, we decided that the Plan does not have to pre-approve a non-powered mattress overlay provided at in-network benefit level to be provided by 
an out-of-network (OON) provider.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the outpatient hospital services, and Part B 
medication services provided on November 17, 2021. 
 
You asked the Plan to waive the cost share for the outpatient hospital services and Part B medication services. 
You say that you feel you should not be responsible for this cost share amount, and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received outpatient hospital services 
and Part B medications on the date of service at issue in this appeal. The Plan says that the correct cost share 
has applied per your contract with the Plan. 
 
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 $350 
copayment for Outpatient surgery and other medical services provided at a hospital outpatient facility and a 
20% coinsurance for Medicare Part B prescription drugs. 
 
The records show you had not met your maximum out-of-pocket (MOOP) at the time this claim was processed. 
The records also shows that other claims were reprocessed which caused you to fall below the $5700 MOOP 
amount. You have been asked to pay a $74.67 copayment for the outpatient hospital services provided on 
November 17, 2021, which is less than the contracted $350 copayment amount. The outpatient hospital 
services fall within the Outpatient surgery and other medical services benefit category. You have also been 
asked to pay a 20% coinsurance for the Part B prescription drugs provided on November 17, 2021, totaling 
$413.10. The Part B prescription drugs fall within the Medicare Part B prescription drugs 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 cost share for the outpatient hospital services, and Part B medication 
services provided on November 17, 2021.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve computed tomography (CT) of the stomach for the enrollee. 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the request cannot be approved because it is only supported once every six months. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
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 scan. Our reviewer says that the 
requested scan is medically reasonable and necessary. Our physician reviewer found the last CT scan in the 
records is from 7/27/21. The enrollee has known cirrhosis. Cirrhosis patients are at risk for hepatocellular 
cancer so the six month surveillance is medically necessary. The enrollee is overdue for this surveillance 
imaging. 
 
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 scan have been met. Therefore, we decided that the Plan has to pre-approve 
computed tomography (CT) of the stomach for the enrollee.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 1 standard power wheelchair and accessories 
for the enrollee. 
 
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied 
your request. The Plan says a home assessment with a written report is to be completed prior to delivery of the 
power mobility device. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the wheelchair. Our reviewer says that 
the requested wheelchair is not medically reasonable or necessary. Our physician reviewer found the provided 
records do not include documentation that the enrollee's home provides adequate access, maneuvering space, 
and surfaces for the operation of the requested device. In addition, the records do not document that the enrollee has sufficient strength and postural stability to transfer to and from and operate the device. 
 
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 wheelchair have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a group 1 standard power wheelchair and accessories for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued oxygen rental. 
 
You asked the Plan to pre-approve the continued oxygen rental. You say that oxygen is medically necessary. 
The Plan denied your request. The Plan says coverage criteria is no longer met. 
 
The Plan must follow Medicare rules. The rules say that for patients with arterial PO2 at or above 60 mm Hg or 
arterial O2 saturation at or above 90%, there is a rebuttable presumption of non-coverage for home oxygen.   
 
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 continued oxygen rental. Our 
reviewer says that continued home oxygen rental is not medically necessary. Our physician reviewer found it is 
not clear from the records whether the patient is receiving and using oxygen currently. The most recent medical 
visit is from March 15, 2022, and oxygen is not mentioned. The SpO2, presumably breathing room air, was 
96%. The qualifying data for oxygen is from 2014. 
 
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 continued oxygen rental have not been met. Therefore, we decided that the 
Plan does not have to pre-approve continued oxygen rental.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for the rotary wing air transport (A0431-QL) provided on July 23, 2021. 
 
You asked the Plan to pay for the rotary wing air transport. The Plan denied your request. The Plan says that 
medical necessity for ambulance service is established when the patient's condition is such that medically 
necessary services are actually furnished, even if a local government requires an ambulance response for all 
calls. The Plan also says that an ambulance response without transport is to be billed with a "-QL" modifier. 
 
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 
We looked at the file and Medicare rules. The record shows that this air ambulance dispatch was requested 
because it was believed to be medically necessary. Based on this information, we decided that Medicare rules 
for coverage of the rotary wing air transport have been met. Therefore, we decided that the Plan has to pay for 
the rotary wing air transport (A0431-QL) provided on July 23, 2021.   
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: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for revision of total knee arthroplasty provided to the enrollee on June 1, 
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 that procedure 27487 is not supported by the medical records submitted. 
 
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 27487 is "Revision of total knee arthroplasty, with or without allograft; femoral and entire tibial 
component." 
 
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 supported by the medical records. Our reviewer found the operative note cites the proximal tibia, 
posterior femoral and anterior femoral cuts were made with a straight blade. The laminar spreader and retractor 
were inserted in the medial compartments were cleaned of menisci and debris. A lamina spreader was placed 
on the medial side. The lateral meniscus was retracted. The trial implants were inserted utilizing a cruciate 
retaining femoral implant. The patella tracked with the trochlea. The trial implants were removed. The tibial 
preparation was completed. The trabecular bone was cleaned. Insertion of the press fit implants proceeded 
starting with the tibia, femur insertion with cement of the polyethylene spacer. The operative note supports that 
a revision of a total knee arthroplasty, femoral and entire tibial component (CPT 27487) was rendered in this 
case. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
revision of total knee arthroplasty provided to the enrollee on June 1, 2021.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Nitro rollator walker with a seat. 
 
You asked the Plan to pre-approve a Nitro rollator walker with a seat. You say that you need this specific brand 
because of your height. The Plan denied your request. The Plan says the previously provided walker meets your 
needs. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that the Plan provided a standard walker with seat on February 14, 2022. A standard walker 
with seat serves the same purpose as a Nitro rollator walker with a seat. Therefore, we decided that the Plan 
does not have to pre-approve a Nitro rollator walker with a seat.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from June 
25, 2021, to June 28, 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 DRG 604 was not supported.  
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 provided with DRG 604 (TRAUMA TO THE SKIN, 
SUBCUTANEOUS TISSUE AND BREAST WITH MCC). 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 services. Our reviewer says that the services at issue in this case were not supported by 
the medical records. Our physician reviewer found the review has determined that records do not support the 
use of DRG 604 in this case. The records do not support the use of diagnosis code 0J9G0ZZ.  
 
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 inpatient hospital services provided to the enrollee from June 25, 2021, to June 28, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eliquis 5 mg tablet. 
 
You asked the Plan to pre-approve Eliquis. You say that this drug is medically reasonable and necessary for the 
enrollee's condition. The Plan denied your request. The Plan says this drug is not covered under the enrollee's 
medical benefit. 
 
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 5 mg tablet.
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 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. 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 there are no services offered at a SNF that are 
not offered at an inpatient rehabilitation facility. Admission to a SNF for inpatient skilled rehabilitation 
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 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from 
March 24, 2021, to April 2, 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 there was a change from DRG 872 to DRG 603.  
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 provided with DRG 872 (SEPTICEMIA OR SEVERE SEPSIS 
WITHOUT MV >96 HOURS WITHOUT MCC). 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 services. Our reviewer says that the services at issue in this case were not supported by the medical 
records. Our physician reviewer found DRG 603: CELLULITIS WITHOUT MCC is more appropriate in this 
case. Per Sepsis 3 criteria, the increase in creatinine would not be evidence of dysregulated immune-mediated 
organ injury. Furthermore, though the lactate was elevated at 6.4, the Sepsis-3 consensus paper does not utilize 
lactic acid in the routine evaluation of sepsis but is instead used only as a marker for septic shock. 
Documentation in the medical record also noted that the lactate cleared to 2 after fluid hydration.  
 
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 inpatient hospital services provided to the enrollee from March 24, 2021, to April 2, 2021.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve plastic surgery (nipple tattooing) services provided on June 17, 
2021. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says that these services are covered when the diagnosis is cancer-related. 
 
The Plan must follow Medicare rules. The rules say that tattooing to correct color defects of the skin may be 
considered reconstructive when performed in connection with a payable post-mastectomy reconstruction.  
 
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 reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that the records show that you have previously undergone mastectomy and free flap. Coverage for the 
requested service is available under this clinical scenario. 
 
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 been met. Therefore, we decided that the Plan has to pre-
approve plastic surgery (nipple tattooing) services provided on June 17, 2021.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on January 13, 
2022. 
 
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 an appropriate modifier was not 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, 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 imaging services provided to the enrollee on January 13, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Ultrasound (76700) provided on January 21, 2022. 
 
You asked the Plan to pay for code 76700. 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 as 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, we have confirmed that code 76700 
is a column II code to column I code 93976. 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 Ultrasound (76700) provided on January 21, 2022.