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

 
We decided that the Plan does not have to pre-approve Lacosamide. 
 
You asked the Plan to pre-approve Lacosamide. You say that the services are necessary. The Plan denied your 
request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Lacosamide.  
 
Benefits for Lacosamide may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 48 units of A6197 provided to the enrollee on March 14, 
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 Healthcare Common Procedure Coding System (HCPCS) A6197 remains not supported, as the 
records do not support the number of units billed. 
 
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 procedure code A46197 is "Alginate or other fiber gelling 
dressing, wound cover, sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in., each dressing." 
 
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 procedure report includes 
insufficient documentation to confirm more than 30 units of service.  Procedure report documents 2 wounds 
treated, however, the wound #1 documentation shows "Apply Gel Fiber Silver 4" x 8" to wound.; Used during 
treatment - Quantity 30"). In this case, the 48 units reported cannot be verified. 
 
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 48 units of A6197 provided to the enrollee on March 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a viscosupplementation injection. 
 
You asked the Plan to pre-approve a viscosupplementation injection. 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. 
 
The Plan follows Medicare rules. Medicare rules say that various Hyaluronan preparations 
(viscosupplementation) for intra-articular injections of the knee are considered reasonable and necessary when 
specific criteria are met. 
 
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 viscosupplementation injection. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found in this case, the 
record indicates that the enrollee has knee pain. The record provided does not include X-ray documentation of 
osteoarthritis of the knee. The record provided does not indicate a trial and failure or contraindication of at least 
3 months of conservative therapy. The elements of the coverage criteria are not satisfied. The requested service 
is not recommended. 
 
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 viscosupplementation injection have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a viscosupplementation injection.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on November 02, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for lab testing. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says the enrollee must receive their care from a network provider (for more information 
about this, see Section 2 in this chapter). In most cases, care the enrollee receives from an out-of-network 
provider (a provider who is not part of our plans network) will not be covered. 
 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 lab testing provided on November 02, 2021, by an 
out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and segmental 
pneumatic appliances (E0656, E0667). 
 
You asked the Plan to pre-approve a pneumatic compression device and appliances. You say that you believe 
the information attached and mentioned above displays medical necessity for the Flexitouch PCD. The Plan 
denied your request. The Plan says the enrollee does not meet the LCD criteria for an advanced lymphedema 
pump as there is no failed four-week trial of a basic pneumatic compression device of either E0650 or E0651. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652) and segmental pneumatic appliances (E0656, E0667).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the electric scooter, power mobility device. 
 
You asked the Plan to pre-approve the electric scooter. You say that based on your conditions which 
considerably limit your mobility all over your body and not just in one specific area, which you believe 
necessitates the coverage of this electric scooter. The Plan denied your request. The Plan says the Medicare 
criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
The file shows that there is no documentation that you have a mobility limitation. The documentation also 
shows that you walk with normal gait and you or your home has not been assessed to see if a POV is 
appropriate. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the electric scooter, power mobility device.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve tumor treatment field therapy (TTFT). 
 
You asked the Plan to pre-approve the TTFT. You say that this treatment is medically needed. The Plan denied 
your request. The Plan says that the enrollee has signs of disease progression meaning that this cannot be 
covered. 
 
The Plan follows Medicare rules. Medicare rules say that TTFT is covered when the criteria from the LCD are 
met. 
 
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 TTFT. Our reviewer says that the 
requested treatment is shown to be medically necessary. Our physician reviewer found all LCD criteria have 
been met, including that there is no evidence of progression by the RANO criteria. 
 
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 TTFT have been met. Therefore, we decided that the Plan has to pre-
approve tumor treatment field therapy (TTFT).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat epidural steroid injection (ESI). 
 
You asked the Plan to pre-approve the repeat ESI. You say that it is felt that another ESI should be allowed. 
The Plan denied your request. The Plan says criteria for an additional ESI are not met. 
 
The Plan follows Medicare rules. Medicare rules say that repeat ESIs may be covered when pain relief of at 
least 50% lasts for at least 3 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 the repeat ESI. Our reviewer says that 
the documentation does not support the medical necessity of the repeat ESI. Our physician reviewer found this 
85-year-old enrollee has chronic low back pain and lower extremity weakness from spinal stenosis, most severe 
at L3-L4. She had an ESI at L4-L5 on September 1, 2022. She had 70-89% percent pain relief for 2 weeks. 
There is no documentation that the patient has greater than 50% pain relief for 3 months as per the LCD 
criteria. Therefore, the request is deemed not medically reasonable or 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 the repeat ESI have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a repeat epidural steroid injection (ESI).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve multiple procedures to the leg tibial arteries. 
 
You asked the Plan to pre-approve the procedures. You say that this is medically necessary. The Plan denied 
your request. The Plan says there is no evidence of a supervised exercise program or equivalent. 
 
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 the procedures. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the documentation does not support the medical necessity of the treatments in question. 
The description of symptoms is not suggestive of limb threatening ischemia. The results of the duplex 
examination are not consistent with leg cramping at night, suggesting a non-vascular etiology for the patients 
symptoms. Treatment of tibial artery stenosis in the absence of limb threat may prove to do more harm than 
good. As noted by the plan, there are no ankle brachial indices (ABIs) and toe pressures provided, information 
that might have supported the providers request if the findings were significant. 
 
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 procedures have not been met. Therefore, we decided that the Plan does not 
have to pre-approve multiple procedures to the leg tibial arteries.
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 you need the IRF care because your legs are weak, 
and you fall often. The Plan denied your request. The Plan says the IRF care is not medically necessary, and 
your needs can be met at a lower level of care such as a skilled nursing facility (SNF). 
 
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 you were admitted for left sided weakness and numbness attributed to an 
exacerbation of multiple sclerosis. Your medical problems are stable, and there are no complex nursing or 
rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a 
need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation 
services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for office visit on July 28, 2022. 
 
You asked the Plan to waive the copayment for office visit. You say that you want to appeal the amount being 
charged. The Plan denied your request. The Plan says this cost sharing was charged 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 $30 
copayment for services obtained from a specialist, or under certain circumstances, treatment by a nurse 
practitioner or physicians assistant or other non-physician health care professionals in a specialists office (as 
permitted under Medicare rules). Covered services include consultation, diagnosis, and treatment by a 
specialist. 
 
 
 
 You have been asked to pay a $30 copayment for office visit. This item/service falls within the 
Physician/practitioner services, including doctor's 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 office visit on July 28, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Leqvio injections. 
 
You asked the Plan to pre-approve the requested Leqvio. You say that the requested drug is medically 
necessary for the enrollee. The Plan denied your request. The Plan says the enrollee has not tried and failed the 
preferred drug, Praluent. 
 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 requested Leqvio. Our reviewer 
says that the requested medication is not considered reasonable and necessary based on step therapy rules. Our 
physician reviewer found the Plan requires a trial of drug Praluent before they will approve the requested drug. 
In this case, the patient has not tried and failed the required drug(s). There is no documentation provided 
indicating that the plans required drug(s) 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 the requested Leqvio have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Leqvio injections.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed (E0265). 
 
You asked the Plan to pre-approve the hospital bed. You say that you need the bed as transferring you to and 
from the bed is difficult for your caregiver and spouse. The Plan denied your request. The Plan says a total 
electric hospital bed is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed (E0265).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (procedure codes 88377 and G0452) 
provided to the enrollee on June 7, 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 use of the -59 modifier is not supported in this case. 
 
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 the denied codes is: 
 
Healthcare Common Procedure Coding System (HCPCS) G0452: 
 
Molecular pathology procedure; physician interpretation and report 
 
CPT 88377: 
 
Morphometric analysis, in situ hybridization (quantitative or semi-quantitative), manual, per specimen; each multiplex probe stain procedure 
 
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 laboratory report does not 
include sufficient documentation to confirm these services. Additionally, the laboratory report does not include 
sufficient documentation to support CPT 88377 as a separate distinct procedure from CPT 81219, and CPT 
81339. Therefore, modifier -59 cannot be verified. 
 
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 laboratory services (procedure codes 88377 and G0452) provided to the enrollee on June 7, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on April 29, 2022. 
 
You asked the Plan to pay for physician's services. You say that the services were medically necessary. The 
Plan denied your request. 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 Plan says that the Plan has 
also determined that these services are not urgent or emergent, nor were they approved in advance. 
 
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 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for physician's services provided on April 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on February 24, 2022. 
 
You asked the Plan to pay for physician's services. You say that the services were medically necessary. The 
Plan denied your request. 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 Plan says that the Plan has 
also determined that these services are not urgent or emergent, nor were they approved in advance. 
 
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 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for physician's services provided on February 24, 2022.