Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from April 27, 2022, to 
May 26, 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 the claim was not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that HHAs must send a Notice of Admission (NOA) to 
Medicare. 
 
We looked at the file and Medicare rules. The file shows that a valid NOA was not submitted for these 
services. The file shows that the NOA was incorrectly submitted with an admit date of July 31, 2021. 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 home health services rendered from April 27, 2022, to 
May 26, 2022.
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 requested drug is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee has not tried and failed one of the preferred 
drugs, Orthovisc or Supartz FX. 
 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 Euflexxa. Our reviewer says that the 
step therapy criteria have no been met. Our physician reviewer found the provided documentation does not 
support that the enrollee has tried and failed the preferred drugs. The reviewer found that the documentation 
does not outline contraindications or reasons these medications were not considered or that the plans 
additional required drug would likely be less effective and/or likely have adverse effects for the enrollee. 
Therefore, the reviewer found that the step therapy criteria have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa (J7323).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a subsequent positron emission tomography (PET) with 
concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization 
imaging; skull base to mid-thigh (77815). 
 
You asked the Plan to pre-approve a subsequent PET and CT scan. You say that the enrollee needs a PET/CT 
scan. The Plan denied your request. The Plan says the medical records do not suggest that there are clinical 
concerns for recurrent or metastatic disease, with normal tumor markers and no clinical complaints or physical 
exam findings. 
 
The Plan must follow Medicare rules. Medicare rules say that PET 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 a subsequent PET and CT scan. Our 
reviewer says that the PET and CT scan is not medically necessary. Our physician reviewer found that the PET 
and CT scan is for surveillance and the enrollee has already had three PET and CT scans. CT scans can be 
considered as an alternative.  
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 subsequent PET and CT scan have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a subsequent positron emission tomography (PET) with concurrently 
acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; skull base 
to mid-thigh (77815).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Synvisc (J7325). 
 
You asked the Plan to pre-approve Synvisc. You say that the requested drug is a medical necessity for you. The 
Plan denied your request. The Plan says step-therapy rules for the requested drug have not been 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 Synvisc. Our reviewer says that the 
requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the 
Plan requires a trial of Euflexxa before they will approve the requested drug. The requested drug is a new 
start. The provided records do not indicate that you have tried and failed the Plan's preferred step-one 
alternative. The record does not indicate that you have a contraindication to, or would have an adverse effect 
from, the Plan's preferred step-one alternative. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Synvisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve treatment with Synvisc (J7325).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for measurement of immunoglobulin light chains provided on 
July 27, 2022. 
 
You asked the Plan to pay for measurement of immunoglobulin light chains. You say that this procedure is 
beneficial to your health condition. The Plan denied your request. The Plan says this services is determined to 
be experimental, investigational and unproven for all diagnoses and for all plans. 
 
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 measurement of immunoglobulin light 
chains have been met. Specifically, medical records were not provided. Per Medicare, to consider coverage and 
payment for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. Therefore, we decided that the Plan does not have to pay for measurement of immunoglobulin light 
chains provided on July 27, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the records provided support the need for IRF care. 
The Plan denied your request. The Plan says the records do not show that the enrollee needs rehabilitation 
nursing care for 24 hours a day. The Plan says that the records do not show that the enrollee needs at least 3 
doctor visits per week. The Plan says that the enrollee's current needs can be met in a skilled nursing facility. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for urinary tract infection, sepsis, and metabolic encephalopathy. The enrollee's medical problems 
are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by 
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation 
therapy program. While the medical record supports a need for physical and/or occupational therapy, there is 
no documented need for intensive rehabilitation services. Medically necessary care can be provided in a 
different level of care. There is not a reasonable expectation that the enrollee will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Zilretta. 
 
You asked the Plan to pre-approve Zilretta. You say that this drug is medically reasonable and necessary. The 
Plan denied your request. The Plan says step therapy criteria have not been 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 Zilretta. Our reviewer says that the 
requested drug is not medically reasonable and necessary. Our physician reviewer found that the Plan requires 
a trial of dexamethasone injection and methylprednisolone injection before they will approve the requested 
drug. In this case, the record indicates that the enrollee has osteoarthritis of the knee. 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 alternative. 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 alternative. The elements of the coverage criteria are not 
satisfied. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Zilretta have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Zilretta.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the records provided support the need for IRF care. 
The Plan denied your request. The Plan says the records do not show that the enrollee needs or are able to take 
part in 3 hours of therapy a day at least 5 days a week or 15 hours per week. The Plan says that the services 
needed can be provided safely in other settings. The Plan says that IRF care is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for pneumothorax and surgical management of thoracic compression fractures after a motor 
vehicle accident. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation 
needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a 
need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation 
services. Medically necessary care can be provided in a different level of care. There is not a reasonable 
expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation 
therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electric scooter. 
 
You asked the Plan to pre-approve an electric scooter. You say that the requested electric scooter is medically 
necessary for your day-to-day living. You need to be able to do things on your own. You also say you have 
been to many pain doctors, specialists, and many clinics, and your providers say very clearly, that you have 
chronic long-term pain and that you are permanently disabled. The Plan denied your request. The Plan says you 
indicated that you were advised by your primary care physician that you have long term chronic illness and 
need transportation. The medical information received from your primary care physician dated October 28, 
2022, indicates that your gait disorder is stable and recommends a cane. The medical information does not 
indicate that you are unable to perform mobility related activities of daily living with cane, walker, or standard 
wheelchair in the home. 
 
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.  
 
The file shows that you do not have a mobility deficit that impairs your participation in MRADLs, or your 
condition can be improved by a walker, cane, or manual wheelchair. This means that Medicare rules for 
coverage of an electric scooter have not been met. Therefore, we decided that the Plan does not have to pre-
approve an electric scooter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the FreeStyle Libre 14-Day reader device. 
 
You asked the Plan to pre-approve the CGM. You say that the CGM is necessary. The Plan denied your 
request. The Plan says the Medicare rules 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 enrollee is not using insulin multiple times each day. Based on 
this information, we decided that Medicare rules for coverage of the CGM have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the FreeStyle Libre 14-Day reader device.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroiliac (SI) joint fusion. 
 
You asked the Plan to pre-approve sacroiliac joint fusion. The Plan denied your request. The Plan says this is 
not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that SI joint fusion is covered for the indications 
established in the applicable LCD. 
 
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 sacroiliac joint fusion. Our reviewer 
says that the requested services are not medically reasonable and necessary. Our physician reviewer found that 
there is no documented SI joint instability, fracture, or lesion. SI joint fusion for degenerative back pain is 
experimental. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of sacroiliac joint fusion have not been met. Therefore, we decided that the Plan 
does not have to pre-approve sacroiliac (SI) joint fusion.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a basket for a scooter (E1399). 
 
You asked the Plan to pre-approve a basket for a scooter. You say that you need the requested basket for your 
scooter because you use your wheelchair every day and when you go shopping, there is no place to put your 
groceries. The Plan denied your request. The Plan says the basket for a scooter is not covered because it is not 
medical in nature and is regularly and primarily used by persons who do not have a specific medical need for 
them. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a basket for a scooter (E1399).
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Orthovisc injection (J7324) 4 injections per knee. 
 
You asked the Plan to pre-approve Orthovisc injection. You say that the drug must come from specialty 
pharmacy. it's the hospital policy. The Plan denied your request. The Plan says that the medication being 
supplied by a pharmacy. The drug must be supplied by the provider. 
 
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 Orthovisc injection. Our reviewer says 
that the requested items/services is considered medically reasonable and necessary in this case. Our physician 
reviewer found intra-articular injections with hyaluronic acid (Orthovisc) are recommended as a possible 
option for severe osteoarthritis for patients who have not responded adequately to recommended conservative 
treatments (exercise, NSAIDs, and/or Acetaminophen) to potentially delay total knee replacement. While 
osteoarthritis of the knee is a recommended indication, there is insufficient evidence for other conditions, 
including patellofemoral arthritis, chondromalacia patellae, osteochondritis dissecans, or patellofemoral 
syndrome (patellar knee pain). Hyaluronic acids are naturally occurring substances in the body's connective 
tissues that cushion and lubricate the joints. Intra-articular injection of hyaluronic acid can decrease symptoms 
of osteoarthritis of the knee; there are significant improvements in pain and functional outcomes with few 
adverse events. The review has determined that the documentation supports that the Orthovisc injection is 
medically reasonable and necessary for the enrollee. The documentation supports that the Orthovisc injection is 
safe and effective for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Orthovisc injection have been met. Therefore, we decided that the Plan has to 
pre-approve Orthovisc injection (J7324) 4 injections per knee.  
 
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 procedure code 64483 billed for date of service February 23, 
2022.  
You asked the Plan to pay for procedure code 64483. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 64483 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 64483 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 64483 billed for date of service February 23, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical stimulator supplies, 2 lead, per month, (e.g., 
TENS, NMES) (A4595) provided July 2, 2022. 
 
You asked the Plan to pay for the electrical stimulator supplies. You say that the claim was billed in accordance 
with the enrollee's Plan policy allowable, accepted procedure codes and diagnosis codes according to Plan type. 
The Plan denied your request. The Plan says evidence of misrepresented services. 
 
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, or relevant medical records which support medical necessity for the supplies provided in this case. Specifically, the Plan confirmed from the office of the ordering 
provider indicated that they did not order the item. Also, the documentation submitted did not sufficiently 
support the billed supply code. 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 electrical 
stimulator supplies, 2 lead, per month, (e.g., TENS, NMES) (A4595) provided July 2, 2022.