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

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) services. 
 
You asked the Plan to pre-approve RFA services. You say that the records provided support the need for RFA 
services. The Plan denied your request. The Plan says research has not proven the requested treatment to be 
helpful. The Plan says that RFA is considered experimental and investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
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 RFA services. Our reviewer says that 
RFA services are not considered medically reasonable and necessary in this case. Our physician reviewer found 
for individuals who have sacroiliac (SI) joint pain who receive therapeutic corticosteroid injections, the 
evidence includes small randomized controlled trials and case series. Relevant outcomes are symptoms, 
functional outcomes, quality of life, medication use, and treatment-related morbidity. In general, the literature 
on injection therapy of joints in the back is of poor quality. Based on the established use of injections to treat 
pain in other joints, the evidence is sufficient to determine the effects of the technology on health outcomes for 
therapeutic (corticosteroid) injections. The clinical value and effectiveness of radiofrequency ablation to the SI 
joint in the setting of sacroiliac dysfunction have not been demonstrated in the peer-reviewed literature.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of RFA services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve radiofrequency ablation (RFA) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom fabricated, plastic ankle foot orthosis with 
ankle joint (L1970). 
 
You asked the Plan to pre-approve a custom fabricated, plastic ankle foot orthosis with ankle joint (L1970). 
You say that the requested custom fabricated, plastic ankle foot orthosis with ankle joint (L1970) is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for a custom 
fabricated, plastic ankle foot orthosis with ankle joint (L1970). 
 
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 custom fabricated, plastic ankle foot 
orthosis with ankle joint (L1970). Our reviewer says that the enrollee does not meet criteria for a custom 
fabricated, plastic ankle foot orthosis with ankle joint (L1970). Our physician reviewer found the LCD L33686 
criteria have not been met for a custom L1970 ankle foot orthosis (AFO). The documentation does not reveal 
physical exam findings of weakness of the foot and ankle. The documentation on December 6, 2021, states 
there is moderate edema on the left retrocalcaneal surface. There is no clubbing, inflammation, asymmetry, 
crepitation, defects, masses, or effusions. The range of motion reveals no contracture of the feet. There is no 
dislocation, subluxation, or laxity in the feet. There is a slightly enlarged area likely due to scar on the left 
ankle. There are no objective exam findings of instability supporting that the enrollee requires the L1970 or 
requires stabilization for medical reasons, and that the L1970 has the potential to benefit the enrollee 
functionally. The documentation does not reveal that the enrollee could not be fit with a prefabricated AFO or 
that the orthosis will be permanent for more than 6 months. The documentation does not reveal a need to 
control the knee, ankle or foot in more than one plane; or that the enrollee has a healing fracture which lacks 
normal anatomical integrity or anthropometric proportions. 
 
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 custom fabricated, plastic ankle foot orthosis with ankle joint (L1970) have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a custom fabricated, plastic 
ankle foot orthosis with ankle joint (L1970).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the biceps tendon procedure provided on October 20, 2021, 
billed with code 23430-AS-59-RT. 
 
You asked the Plan to pay for the tendon procedure as billed. You say that this should be paid. The Plan denied 
your request. The Plan says the edit between these codes cannot be bypassed when done on the same side.  
The Plan must follow Medicare rules. Medicare rules say that when a PTP edit exists between two codes, the 
Column 2 code is only payable when a clinically appropriate modifier is used. The rules further state, however, 
that for an edit between two shoulder-related procedures exists, a modifier can only bypass the edit when the 
two procedures are done on opposite shoulders.   
 
We looked at the file and Medicare rules. Code 23430 is a Column 2 code in relation to code 23472. These are 
both shoulder-related procedures. Although a modifier was used, the procedures were both done on the right 
shoulder, meaning that the edit cannot be bypassed. Based on this information, we decided that Medicare rules 
for coverage of the tendon procedure as billed have not been met. Therefore, we decided that the Plan does not 
have to pay for the biceps tendon procedure provided on October 20, 2021, billed with code 23430-AS-59-RT.
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 you need this care. The Plan denied your request. 
The Plan says this is not medically necessary. 
 
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 the records do not show that you have 
identifiable skilled therapy service needs. While you have skilled therapy needs, you do not require therapy on 
a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled 
nursing facility setting. 
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an x-ray examination of the foot (73630) 
provided on December 2, 2021. 
 
You asked the Plan to waive the copayment for an x-ray examination of the foot. You say that this service 
billing was for x-rays for the post-operation that was performed on October 21, 2021. The Plan denied your 
request. The Plan says you were charged the correct cost sharing amount. The Plan also says that diagnostic 
tests and procedures, including diagnostic radiological procedures are not included in the global surgical 
package. 
 
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 $15 
copayment for each Medicare-covered standard x-ray service. 
 You have been asked to pay a $15 copayment for an x-ray examination of the foot. An x-ray examination of the 
foot falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This 
means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayment for an x-ray examination of the foot (73630) provided on 
December 2, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Remede system. 
 
You asked the Plan to pre-approve a Remede system. You say that you have attempted but failed conventional 
treatments. You say that without the requested treatment, you are at risk of severe co-morbid medical 
conditions, increased risk of motor vehicle accident and reduced daytime productivity due to life altering 
chronic fatigue. You say that the Remede system offers clear and substantial benefit in patients with central 
sleep apnea, leading to improvement in the enrollee's quality of life. You say that CMS granted the Remede 
system transitional pass-through payment in November of 2018. The Plan denied your request. The Plan says 
the requested device has not been shown to be safe and effective in long term studies. 
 
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 Remede system. Our reviewer says 
that a Remede system is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has complex sleep apnea with central apneas that increase with higher continuous 
positive airway pressure (CPAP) pressures.  However, there has not been an adequate titration of CPAP at 
lower pressures, or of bi-level positive airway pressure (Bi-PAP) or adaptive servo ventilation (ASV.)  There has been no home trial of positive airway pressure therapy. The Remede system has not been adequately 
studied or compared with positive airway pressure therapy and is considered experimental in this regard. 
 
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 Remede system have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Remede system.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture, 1 or more needles; without electrical 
stimulation, initial 15 minutes (97810), acupuncture, 1 or more needles; without electrical stimulation, each 
additional 15 minutes (97811), acupuncture, 1 or more needles; with electrical stimulation, each additional 15 
minutes (97814) and an application of a modality to 1 or more areas (97026) provided on February 5, 2021, to 
June 16, 2021. You asked the Plan to pay for acupuncture services. You say that you are requesting reconsideration and have 
submitted medical records to show medical necessity. The Plan denied your request. The Plan says services 
were rendered by a non-covered provider type. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the 
Plans rules apply in this case.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the health Plan contract specifically says that 
acupuncture must be provided by a legally qualified physician practicing within the scope of their license. The 
services were rendered by an acupuncturist, not a physician. Therefore, we decided that the Plan does not have 
to pay for acupuncture, 1 or more needles; without electrical stimulation, initial 15 minutes (97810), 
acupuncture, 1 or more needles; without electrical stimulation, each additional 15 minutes (97811), 
acupuncture, 1 or more needles; with electrical stimulation, each additional 15 minutes (97814) and an 
application of a modality to 1 or more areas (97026) provided on February 5, 2021, to June 16, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the cost share for a Durolane injection provided on October 2, 2021. 
 
You asked the Plan to waive the cost share for an injection. You say that this medication was ordered by your 
provider. You also say that you were not informed that you would be charged for the medication. The Plan 
denied your request. The Plan says that you have been charged the correct cost sharing amount. 
 
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 did not provide the 2021 Schedule of Cost Sharing. Without the 
Schedule of Cost Sharing, we are unable to determine if the cost share applied is correct. Therefore, we decided 
that the Plan has to waive the cost share for a Durolane injection provided on October 2, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gene analysis (prothrombin, coagulation factor II) A 
variant (81240). 
 
You asked the Plan to pre-approve the genetic testing. You say that this blood test is necessary as part of the 
enrollee's evaluation for hypercoagulability. The Plan denied your request. The Plan says Medicare does not 
cover this type of genetic test. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the genetic testing have not been met. Therefore, we decided that the Plan does not have to pre-
approve gene analysis (prothrombin, coagulation factor II) A variant (81240).
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 the requested Zilretta brand is medically necessary. 
The Plan denied your request. The Plan says the requested brand Zilretta is not medically necessary, and the 
enrollee is approved for the generic brand triamcinolone. 
 
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 Zilretta. Our reviewer says that the 
requested brand Zilretta is not medically necessary. Our physician reviewer found based on the medical records 
provided and the Medicare-approved major drug compendia there is no documentation that brand name Zilretta 
is more medically appropriate for the enrollee in this case over the generic triamcinolone. Documentation in the 
Zilretta manufacturer's prescribing information includes a clinical study showing no significant difference in 
efficacy of Zilretta versus generic immediate release triamcinolone. In addition, the efficacy and safety of 
repeat administration of Zilretta have not been demonstrated. 
 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued glucose monitor supplies coded as A9276. 
 
You asked the Plan to pre-approve the requested device. You say that this should be covered under your plan. 
The Plan denied your request. The Plan says non-therapeutic supplies are not covered 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 We looked at the file and the rules. We find that requested continuous glucose monitor was not requested with 
a valid CPT code. Based on this information, we decided that Medicare rules for coverage of the requested 
device have not been met. Therefore, we decided that the Plan does not have to pre-approve continued glucose 
monitor supplies coded as A9276.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for urgent care services on November 12, 
2021. 
 
You asked the Plan to waive the copayment for urgent care services. You say that you were unaware that you 
would have to attend a follow-up visit. The Plan denied your request. The Plan says the copayment applied was 
correct. 
 
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 $65 
copayment for Urgent care services.  
 
You have been asked to pay $65 copayment for urgent care services. Urgent care services fall within the 
Urgently needed services benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for urgent care 
services on November 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist telehealth visit provided on 
October 5, 2021. 
 
You asked the Plan to waive the copayment for the specialist telehealth visit. You say that you thought there 
was no copayment with virtual visits. The Plan denied your request. The Plan says the enrollee saw a specialist 
and had a virtual visit instead of going in for an office visit. Therefore, the proper copayment applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10 
copayment for a Specialty Care Physician including telehealth services, including primary care visits, specialist 
visits, preventive care visits, mental health and psychiatry visits, outpatient substance use visits, opioid 
treatment services, outpatient rehabilitation, podiatry visits, vision exams, hearing exams and dental visits.  
 
  You have been asked to pay a $10 copayment for the specialist telehealth visit. The specialist telehealth visit 
falls within the Physician/Practitioner services, including doctors office visits 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 telehealth visit provided on October 5, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Skilled Nursing Facility (SNF) services. 
 
You asked the Plan to pre-approve the SNF services. You say that you would like reconsideration because the 
SNF services are medically necessary. The Plan denied your request. The Plan says you do not meet Medicare 
criteria for coverage of the SNF services. 
 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 the SNF services. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found there is no documentation that you 
require the services on an inpatient basis, only in a skilled nursing facility setting. Services in the home with 
home health care or in a long-term care facility on a part time basis appear appropriate in this case. 
 
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 SNF services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the Skilled Nursing Facility (SNF) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory work provided on September 3, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory work. You say that the laboratory work was medically necessary. 
The Plan denied your request. The Plan says no prior authorization was obtained. 
 
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 did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The 
records provided for review do not show that the service at issue was urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for laboratory work provided on September 3, 2021, by an out-of-
network (OON) provider.