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

 
We decided that the Plan does not have to pre-approve a genicular nerve ablation. 
 
You asked the Plan to pre-approve a genicular nerve ablation. You say that the requested genicular nerve 
ablation is medically necessary. The Plan denied your request. The Plan says the requested genicular nerve 
ablation is not medically 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 a genicular nerve ablation. Our 
reviewer says that the requested genicular nerve ablation is not medically necessary. Our physician reviewer 
found the role of genicular radiofrequency ablation is still being evaluated. It is considered 
experimental/investigational. 
 
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 ablation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a genicular nerve ablation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Assure brand automatic external defibrillator (AED) 
garment (K0606). 
 
You asked the Plan to pre-approve the Assure brand AED garment. The Plan denied your request. The Plan 
says the company you are requesting to receive this DME from is a non-contracted DME provider with the 
Plan. The Plan also says there are contracted DME providers that can supply the DME if medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare Advantage organizations may limit 
coverage to certain Durable Medical Equipment (DME) brands, items, and supplies. 
 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Assure brand AED garment have not been met. Specifically, the Plan does not cover the Assure 
brand AED garment. Therefore, we decided that the Plan does not have to pre-approve an Assure brand 
automatic external defibrillator (AED) garment (K0606).  
 
Please Note: You can contact the Plan for more information about how to get a preferred-brand AED garment
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the influenza vaccine rendered on July 21, 2021. 
 
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 drug claims must be billed with revenue code 0636. 
 
We looked at the file and Medicare rules. The file shows that the claim was not billed with revenue code 0636. 
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 influenza vaccine rendered on July 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye refraction provided on January 27, 2022. 
 
You asked the Plan to pay for an eye refraction. The Plan denied your request. The Plan says you received a 
comprehensive eye exam with refraction for the diagnosis of combined forms of age-related cataracts, bilateral. 
eye refractions are only covered by the Plan if performed by a participating vision provider and performed as a 
routine screening per the 2022 Evidence of Coverage. 
 
The Plan must follow Medicare rules. Medicare does not pay for procedures performed in the course of any eye 
exam to determine the refractive state of the eyes. Refractive procedures are not covered even when done in 
connection with otherwise covered diagnosis or treatment of illness or injury. 
 
We looked at the file, the Plans rules and the Medicare rules. Medicare does not pay for procedures performed 
in the course of any eye exam to determine the refractive state of the eyes. The Plan covers eye refractions only 
when performed by a participating vision provider and performed as a routine screening. The file shows that 
you received they eye refraction for a medical diagnosis of age-related cataracts. Therefore, we decided that the 
Plan does not have to pay for an eye refraction provided on January 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve medial branch block procedures (64493, 64494). 
 
You asked the Plan to pre-approve medial branch blocks. You say that the requested services are a medical 
necessity for you. The Plan denied your request. The Plan says the requested services are not medically 
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 medial branch blocks. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the records show that the pain radiates into your right and left legs, which is a 
radicular pattern of pain. Furthermore, the magnetic resonance imaging (MRI) scan shows that you have a disc herniation which compresses a nerve. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of medial branch blocks have not been met. Therefore, we decided that the Plan 
does not have to pre-approve medial branch block procedures (64493, 64494).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 
You asked the Plan to pre-approve Euflexxa. You say that you do not carry Orthovisc in stock. You say that if 
they send the script for Orthovisc to the pharmacy, the enrollee is responsible for a $1,651.97 copayment. You 
say that the enrollee has no way of paying since she is on a limited income. You say that they are trying to keep 
the enrollee form getting a knee replacement. You say that the enrollee is in agony from the pain and does not 
want to go to the hospital. The Plan denied your request. The Plan says they don't have record showing that the enrollee has tried one of the preferred drugs or that there are medical reasons that prevent them from using one 
of the preferred drugs. 
 
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 
criteria for coverage have not been met. Our physician reviewer found the Plan requires a trial of drugs 
Orthovisc, Synvisc or Synvisc One before they will approve the requested drug. In this case, the enrollee has 
not tried and failed the required drugs. There is no documentation provided indicating that the Plans required 
drugs would likely be less effective and/or likely have adverse effects 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 Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary for the enrollee. The Plan 
denied your request. The Plan says this is not medically necessary, the enrollee is able to get the necessary 
rehabilitation, such as physical therapy and occupational therapy at the current level of care with the goal of 
safely returning member to home. 
 
 
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 enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. There is no documented need for intensive rehabilitation services and medically necessary 
care can be provided in a different level of care. 
 
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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied 
your request. The Plan says that the coverage criteria has not been met. 
 
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 that the enrollee does not have any complex nursing or rehabilitation needs. 
Medically necessary care can be provided in a different level of care. 
 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 IRF admission and services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee from October 1, 2020, to October 10, 2020. 
 
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 provider has reported skilled services with the incorrect PDPM Health Insurance Prospective 
Payment System (HIPPS) Score. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the records do not support that the 
care was clinically complex. The medical records support the presence of a surgical wound, but not one that 
required skin treatment. 
 
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 skilled nursing facility (SNF) services provided to the enrollee from October 1, 2020, to 
October 10, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on March 27, 
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 the claim was denied correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
 
 
 
 
 
 
 
 
 These services should not have been reported separately, as the enrollee was inpatient at the time of service. 
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 laboratory services provided to the enrollee on 
March 27, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97530 billed for date of service February 11, 
2022. 
 
You asked the Plan to pay for procedure code 97530. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 97530 is bundled into payment for code 92526.  
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 97530 
is a column II code to column I code 92526. 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 procedure code 97530 billed for date of service February 11, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes G0439, G0444 and G0442 billed for date of 
service May 13, 2022. 
 You asked the Plan to pay for procedure codes G0439, G0444 and G0442. You say that you would like this 
claim reprocessed based on medical necessity. The Plan denied your request. The Plan says payment for code 
G0439, G0444 and G0442 is bundled into payment for code 99483. 
 
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 codes 
G0439, G0444 and G0442 are all column II codes to column I code 99483. 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 procedure codes G0439, G0444 and 
G0442 billed for date of service May 13, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an out-of-network referral for magnetic resonance 
imaging (MRI) of the lower extremity 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says the service is available from a provider in the network. 
 
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 
an out-of-network referral for magnetic resonance imaging (MRI) of the lower extremity
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance transport rendered on January 1, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim is a duplicate. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on February 17, 2022. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for these services have not been met. Therefore, 
we decided that the Plan does not have to pay for the ambulance transport rendered on January 1, 2022.
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 8, 
2022. 
 You asked the Plan to pay for procedure code 64483. You say that you disagree with the 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 8, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on October 25, 2021 . 
 
You asked the Plan to pay for ambulance services. You say that the auto insurance has processed the claim so 
additional payment should be made. The Plan denied your request. The Plan says the allowed amount for these 
services has been paid. 
 
The Plan must follow Medicare rules. Medicare rules say that contractors may pay Medicare secondary 
benefits when a provider, physician, or other supplier, or beneficiary submits a claim that is payable under 
Medicares coverage requirements and the primary plan does not pay the entire charge. Contractors can process Medicare secondary payment when the primary plans payment is less than the gross amount payable by 
Medicare. 
 
We looked at the file and Medicare rules. The record shows that the primary plan paid the allowed amount for 
these services. Based on this information, we decided that Medicare rules for coverage of ambulance services 
have not been met. Therefore, we decided that the Plan does not have to pay for ambulance services provided 
on October 25, 2021 .
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services provided on June 22, 2022, by an out-
of-network (OON) provider. 
 
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 the provider is non-participating, and the services were not authorized 
by the Plan. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the surgical services provided on June 22, 2022, 
by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (A4556, A4557, A4649, A9279, S1015, S8301, 
99072) provided on April 20, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services are 
not payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure codes A9279, S1015, and S8301 have a status indicator of I on the Physician Fee 
Schedule. This means that procedure codes A9279, S1015, and S8301 are not valid for Medicare purposes. We 
also find that procedure codes A4556, A4557, and A4649, have a status indicator of P on the Physician Fee 
Schedule. This means that no payment cannot be made for these services. Finally, procedure code 99072 is 
assigned a status indicator of B on the Physician Fee Schedule. This means that procedure code 99072 is not 
separately payable. Based on this information, we decided that Medicare rules for coverage of the billed codes 
have not been met. Therefore, we decided that the Plan does not have to pay for the services (A4556, A4557, 
A4649, A9279, S1015, S8301, 99072) provided on April 20, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee meets the criteria for IRF placement and 
has enough medical and physical complexity to support this discharge plan. The Plan denied your request. The 
Plan says criteria for admission to the IRF have not been met. 
 
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 enrollees nursing, medical and rehabilitation needs do not 
require an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While 
the medical record supports a need for physical or occupational therapy, there is no documented need for 
intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
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 IRF admission and services.