Persius/hicric huggingface dataset:
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 the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has 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 Euflexxa. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the documentation does not outline 
contraindications or reasons these medications were not considered or that the plan's additional required drug 
would likely be less effective and/or likely have adverse effects for the enrollee. Without the support of the 
documentation, Euflexxa is not approved as step criteria has 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.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 10035 billed for date of service September 
16, 2021. 
 
You asked the Plan to pay for procedure code 10035. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 10035 is bundled into payment for code 19083.  
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 10035 
is a column II code to column I code 19083. 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 10035 billed for date of service September 16, 
2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health aide (HHA) services for 2 additional hours 
per day from Monday to Friday. 
 
You asked the Plan to pre-approve additional HHA services. The Plan denied your request. The Plan says you 
do not qualify for HHA services for 5 hours a day, Monday to Friday, because it is considered custodial care. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or 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 HHA services. Our reviewer 
says that home health services including associated HHA services are not shown to be medically necessary or 
reasonable. Our physician reviewer found you do not have documented skilled nursing needs. Our reviewer 
also found that you do not have documented skilled therapy needs. 
 
 
 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 HHA services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health aide (HHA) services for 2 additional hours per day from Monday to 
Friday.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the diabetic shoes/inserts you received on 
April 13, 2022. 
 
You asked the Plan to waive the services. You say that you already paid your copayment. The Plan denied your 
request. The Plan says the claim processed correctly. 
 
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 20% 
coinsurance and $10 copayment for diabetic shoes/inserts.  
 
Review of the file shows that you were provided diabetic shoes/inserts on April 13, 2022. You have been asked 
to pay a 20% coinsurance and $10 copayment for the services. The services fall within the diabetic durable 
medical equipment 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 diabetic 
shoes/inserts you received on April 13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87801 billed for date of service May 10, 
2022. 
 
You asked the Plan to pay for procedure code 87801. You say that this service was medically necessary and 
was reported correctly. The Plan denied your request. The Plan says there is a more appropriate code to 
describe the services provided. 
 
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 87801 is infectious agent detection by nucleic acid (DNA 
or RNA), multiple organisms; amplified probe(s) technique. 
 
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 procedure code 87801. Our reviewer says that the medical 
records do not support the billing of CPT code 87801. Our reviewer found the laboratory report describes a 
molecular urinary tract infection, and in this case, there is a more appropriate code to report for the service 
provided. Code 87801 is not supported. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 87801 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 87801 billed for date of service May 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat epidural steroid injection (ESI) (62323). 
 
You asked the Plan to pre-approve a repeat injection. You say that the repeat ESI is medically necessary. The 
Plan denied your request. The Plan says the requested ESI is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that repeat epidural steroid injections (ESI) when the first 
injection directly and significantly provided improvement of the condition being treated may be considered 
medically reasonable and necessary when the medical record documents at least 50% of sustained 
improvement in pain relief and/or improvement in function measured from baseline using the same scale for at 
least three months. 
 
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 repeat injection. Our reviewer says 
that the repeat ESI is not medically necessary. Our physician reviewer found the provided documentation 
indicates the enrollee had an epidural steroid injection a few weeks ago that provided 50% pain relief for a 
period of four days. Therefore, the reviewer found that the criteria for coverage 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 a repeat injection have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a repeat epidural steroid injection (ESI) (62323).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for rotary wing air mileage (A0436) and rotary wing air 
transport (A0431) provided on February 23, 2022. 
 
You asked the Plan to pay for rotary wing air mileage (A0436) and rotary wing air transport (A0431). You say 
that the emergency medical services (EMS) providers play no role in deciding whether or when to transport a 
patient via emergency air ambulance. You also say that the EMS providers respond to calls from first 
responders and treating physicians. The Plan denied your request. The Plan says the information does not 
support the criteria for air ambulance transport. The Plan also says that an appropriate medical facility was 
closer than the destination requested by the family, and the patient did not require air transport to the closer 
facility. 
 
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 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 rotary wing air mileage (A0436) and rotary 
wing air transport (A0431). Our reviewer says that this service does not meet criteria. Our physician reviewer 
found the documentation found that the patient suffered from an illness or injury that contraindications 
transportation by any means other than ambulance. Our physician reviewer also found that the documentation 
did not support that the patient's condition was such that the time needed to transport a patient by ground, or the 
instability of transportation by ground, posed a threat to the patient's survival or seriously endangered the 
patient's health. Our physician reviewer also found that the enrollee could have been adequately treated at the 
closer hospital. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of rotary wing air mileage (A0436) and rotary wing air transport (A0431) have not 
been met. Therefore, we decided that the Plan does not have to pay for rotary wing air mileage (A0436) and 
rotary wing air transport (A0431) provided on February 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve visual field testing (0379T). 
 
You asked the Plan to pre-approve the visual field testing. You say that this service is medically necessary. The 
Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that repeated examinations for diagnosis of macular 
degeneration or central vision loss are not medically necessary unless changes in vision are documented, or to 
evaluate the results of a surgical intervention. 
 
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 visual field testing. Our reviewer 
says that this service is not medically necessary. Our physician reviewer found the record does not show any 
recent visual changes or the need to evaluate the results of a surgical intervention. The enrollee previously had 
visual field testing in 2021. 
 
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 visual field testing have not been met. Therefore, we decided that the Plan 
does not have to pre-approve visual field testing (0379T).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair. 
 
You asked the Plan to pre-approve a power wheelchair. You say that the records provided support the need for 
the requested power wheelchair. The Plan denied your request. The Plan says Medicare does not cover durable 
medical equipment (DME) in a SNF. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that a power wheelchair is being requested for use in a SNF. Therefore, we decided that the Plan 
does not have to pre-approve a power wheelchair.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an advanced knee and foot for the approved prosthesis. 
 
You asked the Plan to pre-approve an advanced knee and foot for the approved prosthesis. You say that the 
requested advanced knee and foot for the approved prosthesis is medically necessary. The Plan denied your 
request. The Plan says that the enrollee does not meet criteria for the requested advanced knee and foot. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan has only provided the addendum note from the July 7, 2022, visit and 
did not provide the rest of the medical records from the in-network providers the Plan used in their review to 
deny services. Per Medicare rule the Plan has not provided the necessary information in support of their denial. 
Therefore, we decided that the Plan has to pre-approve an advanced knee and foot for the approved prosthesis.  
 
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: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 20930 billed for date of service October 13, 
2021. 
 
You asked the Plan to pay for procedure code 20930. You say that the claim should be processed for payment 
of $8,490. The Plan denied your request. The Plan says procedure code 20930 is considered bundled and not 
separately 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 code 20930 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 20930 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 20930 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 20930 billed for date of service October 13, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 85027 and 80050 billed for date of service 
June 17, 2020. 
  You asked the Plan to pay for procedure codes 85027 and 80050. You say that the records are attached for 
review and the claim should be reprocessed to pay the rest of the denied codes. The Plan denied your request. 
The Plan says payment for code 85027 is bundled into payment for code 85025 and procedure code 80050 is 
excluded from coverage. 
 
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 85027 
is a column II code to column I code 85025. Although procedure code 85027 has been billed with a modifier, it 
is not an appropriate modifier to bypass the edit. In addition, procedure code 80050 has a status indicator of N 
on the Physician Fee Schedule. This means that procedure code 80050 is considered a non-covered service. 
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 85027 and 80050 billed for date of service June 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital discharge day management rendered on 
December 2, 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 procedure code 99239 is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99239 is hospital discharge day management; more than 
30 minutes. 
 
We find that CPT code 99239 is not supported in the medical record. Specifically, there is no documentation of 
more than 30 minutes of hospital discharge day management. 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 hospital discharge day management rendered on December 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit with a determination 
of refractive state provided on January 25, 2022. 
 
You asked the Plan to waive the copayment for a specialist office visit with a determination of refractive state. 
You say that there is confusion with you actually receiving the lenses. You also say that you called, and the 
provider gave you a fraudulent prescription. The Plan denied your request. The Plan says you were 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 $35 
copayment for a specialist's office visit.  
 
 
  You have been asked to pay a $35 copayment for a specialist office visit with a determination of refractive 
state. A specialist office visit with a determination of refractive state falls within the Vision Care 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 a specialist office visit with a determination of 
refractive state provided on January 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the power scooter provided on March 11, 2022. You asked the Plan to pay for the services provided. You say that the scooter was purchased due to your 
limited mobility. The Plan denied your request. The Plan says there was not an evaluation by your provider. 
 
The Plan follows Medicare rules. Medicare rules say that power mobility devices are only covered under 
certain medical indications.  
 
The file does not show that your condition cannot be improved by a walker, cane or manual wheelchair, or that 
your home provides adequate access between rooms for the operation of the device. Based on this information, 
we decided that the Medicare rules for coverage have not been met. Therefore, we decided that the Plan does 
not have to pay for the power scooter provided on March 11, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee meets all the CMS criteria 
for LTACH services. The Plan denied your request. The Plan says the enrollee is receiving appropriate 
inpatient care at the current hospital and can remain there until ready for transfer to a lower level of care or 
discharge. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is receiving appropriate care at the present acute care hospital. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where the 
enrollee is currently receiving 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgery services billed for date of service February 22, 
2022. 
 
You asked the Plan to pay for the services provided. You say that the medical records support the need for the 
procedure. The Plan denied your request. The Plan says the billed code is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 63082 is vertebral corpectomy (vertebral body resection), 
partial or complete, anterior approach with decompression of spinal cord and/or nerve root(s); cervical, each 
additional segment (List separately in addition to code for primary procedure). 
 
 We find that CPT code 63082 is not supported in the medical record. Specifically, the medical records do not 
show that an additional cervical segment of a vertebral corpectomy was provided. Based on this information, 
we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided 
that the Plan does not have to pay for the surgery services billed for date of service February 22, 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 if the enrollee is released to go home, he may be in 
danger of hurting himself. The Plan denied your request. The Plan says these services have been correctly 
denied. 
 
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 enrollee's rehab needs can be safely addressed in a skilled nursing facility with similar functional outcome. 
 
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.