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

 
We decided that the Plan does not have to pre-approve Synvisc-One injections (J7325). 
 
You asked the Plan to pre-approve the Synvisc-One injections. You say that Synvisc-One is medically 
necessary. The Plan denied your request. The Plan says a trial of Euflexxa and Durolane, Gelsyn-3, or Supartz 
FX is required before alternatives can be considered. 
 
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 the Synvisc-One injections. Our 
reviewer says that Synvisc-One is not medically necessary. Our physician reviewer found the records do not 
show a trial of the plan preferred drugs, or any reason they would be unsafe or ineffective. 
 
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 Synvisc-One injections have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Synvisc-One injections (J7325).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Evaluation and Management (E/M) service billed with 
code 99213 for date of service October 5, 2022. 
 
You asked the Plan to pay for code 99213. You say that this patient was seen for chronic pain management. 
The Plan denied your request. The Plan says this E/M service is included in the global package for procedure 
64625. 
 
The Plan must follow Medicare rules. Medicare rules say that the payment amount for procedures includes 
payment for preoperative visits and postoperative visits during the postoperative period.  This postoperative 
period can be either 0, 10, or 90 days.  E/M services provided in the postoperative period must be billed with an 
appropriate modifier to indicate that the E/M service is unrelated to the procedure in order to be paid 
separately. 
 
In this case, this patient had a procedure on October 4, 2022 (code 64625), which is one day prior to the E/M service in dispute.  Procedure code 64625 has a postoperative period of 10 days.  The E/M service in dispute 
occurred during the 10-day postoperative period, and you did not bill this service with any modifier to indicate 
that the E/M service was unrelated to the procedure.  According to Medicare rules, this means that the payment 
for this E/M service is packaged into the global surgical payment.  Until and unless you bill this E/M visit with 
an appropriate modifier, no separate payment can be made. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 99213 have not been met. Therefore, we decided that the Plan does not have to pay for the 
Evaluation and Management (E/M) service billed with code 99213 for date of service October 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thermal destruction of an intraosseous basivertebral 
nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral (64628). 
 
You asked the Plan to pre-approve this service. You say that the requested service is medically necessary for 
the enrollee. The Plan denied your request. The Plan says the requested service 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 this service. Our reviewer says that the 
requested service is not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the intracept procedure is experimental. More research is needed to show safety and efficacy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve thermal destruction of an intraosseous basivertebral nerve, including all imaging guidance; 
first 2 vertebral bodies, lumbar or sacral (64628).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cardiovascular screening panel rendered on February 15, 
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 services are not covered. 
 The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, a cardiovascular screening panel, was requested solely for screening purposes. 
Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not 
have to pay for the cardiovascular screening panel rendered on February 15, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care (99309) provided on 
September 29, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that you want the Plan to pay for the 
services. The Plan denied your request. The Plan says the provider is out-of-network and there was no 
authorization for the services. 
 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 subsequent nursing facility care (99309) provided 
on September 29, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Invitae Comprehensive Neuromuscular Disorders 
Panel (81400, 81329, 81161, 81403, 81404, 81405, 81406, 81407, 81408). 
 
You asked the Plan to pre-approve the Invitae Comprehensive Neuromuscular Disorders Panel. You say that 
this test is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been 
met. 
 
The Plan must follow Medicare rules. Medicare rules say that MolDX will only cover and reimburse tests that 
demonstrate analytical and clinical validity, and clinical utility at a level that meets the Medicare reasonable 
and necessary requirement. MolDX will reimburse approved tests covered for dates of service consistent with 
the effective date of the coverage determination. 
 
We looked at the file and Medicare rules. This genetic test is not approved by MolDX. Based on this 
information, we decided that Medicare rules for coverage of the Invitae Comprehensive Neuromuscular 
Disorders Panel have not been met. Therefore, we decided that the Plan does not have to pre-approve an Invitae 
Comprehensive Neuromuscular Disorders Panel (81400, 81329, 81161, 81403, 81404, 81405, 81406, 81407, 
81408).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for lab services provided on February 16, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services were billed correctly and should be 
paid. The Plan denied your request. The Plan says that the procedure requires modifier 26. 
 
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. Specifically, the Plan's denial rationale and case file submission lack any type of 
citation to any Medicare rule supporting its denial.  In fact, the letter that the Plan issued to you on November 
22, 2022, appears to be a denial letter, but cites to absolutely no reason or support for its denial.  Rather, this 
letter says that the services in dispute were denied "with denial code 5023 hence as per SRT."  However, the 
case file has provided no explanation as to what 'SRT' is or how this denial code was applied.  Further, if 
indeed the Plan's denial is actually that these codes require a modifier, you raised an argument in your appeal as 
to why the modifier is NOT required in this case.  The Plan has made no efforts to address your argument at all.  
The burden is on the Plan to show that its denial is supported and correct.  By failing to provide any direct 
citation of any Medicare rule upon which this denial was based, we find that the Plan has not met its burden. 
Therefore, we decided that the Plan has to pay for lab services provided on February 16, 2022.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on November 8, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the services are not covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental 
services on November 8, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lateral interbody fusion and posterior spinal fusion 
with allograft and interbody biomechanical devices (synthetic cage), L2-L5 (Current Procedural Terminology 
22558, 22853, 22612, 20930, 22614, 22842, and 20936) 
 
You asked the Plan to pre-approve a lateral interbody fusion and posterior spinal fusion with allograft and 
interbody biomechanical devices (synthetic cage). You say that the service is medically necessary. The Plan 
denied your request. The Plan says the service 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 lateral interbody fusion and posterior 
spinal fusion with allograft and interbody biomechanical devices (synthetic cage). Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there are limited large-scale, long-term references showing the safety and efficacy of the requested 
surgery in this clinical setting. There is no compelling rationale presented or extenuating circumstances noted 
to support the medical necessity of this request as an exception. 
 
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 lateral interbody fusion and posterior spinal fusion with allograft and 
interbody biomechanical devices (synthetic cage) have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a lateral interbody fusion and posterior spinal fusion with allograft and interbody 
biomechanical devices (synthetic cage), L2-L5 (Current Procedural Terminology 22558, 22853, 22612, 20930, 
22614, 22842, and 20936)
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pneumatic compression device (E0651) to be provided 
by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the pneumatic compression device. You say that you are the only provider 
in this enrollee's geographical area that can supply the Medi Brio lymphedema pump. The Plan denied your 
request. The Plan says enrollees must receive their medical services from an in-network provider with the 
exception being urgent or emergent services. Non-emergent services with non-contracted providers require 
prior authorization before services being rendered. 
 
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 
pneumatic compression device (E0651) to be provided by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998), 
provided on May 16, 2022. 
 
You asked the Plan to pay for ambulance response and treatment, no transport. You say that the service should 
be covered. The Plan denied your request. The Plan says the plan says the ambulance benefit is a transportation 
benefit. If there is no transport, no covered service has been provided. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on May 16, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for ambulance response and treatment, no transport 
(A0998), provided on May 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an external upper limb tremor stimulator of the 
peripheral nerves of the wrist (Cala Trio device) (K1018), and monthly supplies (K1019 x 5). 
 
You asked the Plan to pre-approve Cala Trio device and supplies. You say that there are no other medication or 
surgical options for the enrollee. You also say that this is the only available treatment for the enrollee. The Plan 
denied your request. The Plan says the requested items are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that while electric nerve stimulation has been 
employed to control chronic intractable pain for some time, its use in the treatment of motor function disorders, 
such as multiple sclerosis, is a recent innovation, and the medical effectiveness of such therapy has not been 
verified by scientifically controlled studies. 
 
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 Cala Trio device and supplies. Our 
reviewer says that the requested Cala Trio device and supplies are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the medical records provided there is no documentation 
that the Cala Trio device at issue in this case meets all Medicare criteria for medically reasonable and necessary 
and 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 Cala Trio device and supplies have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an external upper limb tremor stimulator of the peripheral nerves of the wrist 
(Cala Trio device) (K1018), and monthly supplies (K1019 x 5).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on June 6, 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 there was insufficient information. 
 
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 the services have been met. Despite multiple attempts, progress notes that verify what exactly led to this testing were not provided. This 
information is required.. Therefore, we decided that the Plan does not have to pay for laboratory services 
provided to the enrollee on June 6, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bypass procedure (69990, 61711). 
 
You asked the Plan to pre-approve the bypass procedure. You say that this procedure is medically necessary. 
The Plan denied your request. The Plan says this is not a covered service. 
 
The Plan must follow Medicare rules. Medicare rules say that Extracranial-Intracranial (EC-IC) arterial bypass 
surgery is not a covered procedure when it is performed as a treatment for ischemic cerebrovascular disease of 
the carotid or middle cerebral arteries, which includes the treatment or prevention of strokes. The premise that 
this procedure which bypasses narrowed arterial segments improves the blood supply to the brain and reduces 
the risk of having a stroke has not been demonstrated to be any more effective than no surgical intervention. 
Accordingly, EC-IC arterial bypass surgery is not considered reasonable and necessary. 
 
We looked at the file and Medicare rules. This procedure is not covered under Medicare rules. Based on this 
information, we decided that Medicare rules for coverage of the bypass procedure have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a bypass procedure (69990, 61711).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Home health services (G0299, G0151, G0152) to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the home health services. You say that the services should be covered as 
you disagree with the denial and would like to continue seeing the out-of-network provider. The Plan denied 
your request. The Plan says the services denied correctly as they are non-emergent and the same level of care 
can be provided in-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 
Home health services (G0299, G0151, G0152) to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a right knee genicular nerve branch injection and 
radiofrequency ablation. 
 
You asked the Plan to pre-approve a right knee genicular nerve branch injection and radiofrequency ablation. 
You say that a right knee genicular nerve branch injection and radiofrequency ablation is medically necessary. 
The Plan denied your request. The Plan says the requested right knee genicular nerve branch injection and 
radiofrequency ablation does not meet the Plan's Medical Policy coverage criteria. 
 
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 right knee genicular nerve branch 
injection and radiofrequency ablation. Our reviewer says that the requested right knee genicular nerve branch 
injection and radiofrequency ablation is not considered medically reasonable and necessary. Our physician 
reviewer found that this treatment is the subject of ongoing clinical trials and its role in the treatment of knee 
osteoarthritis is still being investigated. Therefore, at this time, the request is deemed not medically reasonable 
and necessary. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a right knee genicular nerve branch injection and radiofrequency ablation have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a right knee genicular nerve 
branch injection and radiofrequency ablation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit (99204, 99214) to be provided by an out-
of-network (OON) provider. 
 
You asked the Plan to pre-approve the office visit. You say that this service is medically necessary. The Plan 
denied your request. The Plan says there are network providers available. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve an office 
visit (99204, 99214) to be provided by an out-of-network (OON) provider.