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

 
We decided that the Plan does not have to waive the copayment for a diagnostic colonoscopy provided on 
December 29, 2021. 
 
You asked the Plan to waive the copayment for a diagnostic colonoscopy. You say that you should not have 
this copayment. 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 a $300 
copayment for outpatient hospital services.  
 
 
 
 
 
 
 
 You have been asked to pay a $300 copayment for a diagnostic colonoscopy. A diagnostic colonoscopy falls 
within the Medicare-Covered Outpatient Hospital 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 a diagnostic colonoscopy provided on December 29, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from 
October 13, 2020 to October 19, 2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the DRG was downgraded.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 193 (SIMPLE PNEUMONIA AND 
PLEURISY WITH MCC). 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 the services. Our 
reviewer says that the services at issue in this case were not supported by the medical records. Our physician 
reviewer found that the impression for the enrollee was community-acquired pneumonia, ruling out COVID-
19. There was asthma exacerbation. The more appropriate DRG was 194.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided to the enrollee from October 13, 2020 to October 19, 2020.
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 this drug is necessary for the enrollee's condition. 
The Plan denied your request. The Plan says step therapy criteria have 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 this 
drug is not medically reasonable and necessary. Our physician reviewer found the Plan requires a trial of 
Orthovisc, Synvisc, and Synvisc One 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 Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the arthroscopy, shoulder, surgical (29827). 
 
You asked the Plan to pre-approve the surgical procedure. You say that this procedure is FDA approved and 
you fit all the criteria for doing this procedure especially your age, condition of the shoulder joint and your 
good general health. The Plan denied your request. The Plan says this procedure is not medically necessary for 
the enrollee's medical condition. 
 
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 surgical procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this enrollee was being treated for unspecified rotator cuff tear or rupture of right 
shoulder. He presented with right shoulder pain. The subacromial injection only helped for a few days. The 
pain is rated at 3/10. The right shoulder exam reveals forward flexion 180, abduction 180, external rotation 45, 
internal rotation L1, with pain at extremes of motion as well as crepitation. Strength is 5-/5 in supraspinatus, 
external rotators, and subscapularis. There is moderate tenderness to palpation of the biceps tendon, and 
minimal at the lateral aspect of the shoulder and AC joint. However, there is limited published, large-scale, long-term peer-reviewed literature that shows this request to be an effective and/or safe treatment for the noted 
pathology. There is no compelling rationale presented or extenuating circumstances noted to support the 
medical necessity of this request as an exception. Therefore, the requested right shoulder InSpace Balloon 
Arthroplasty (CPT 29827), in this case, is 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 surgical procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the arthroscopy, shoulder, surgical (29827).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CX Bladder Detect test provided to the enrollee on 
February 3, 2022. 
 
You asked the Plan to pay for the test. You say that this was medically necessary. The Plan denied your 
request. The Plan says the denial of the CX Bladder Detect test was appropriate given the clinical scenario. 
 
The Plan must follow Medicare rules. Medicare rules say that the current literature does not support the use of 
the CxBladder detect test. 
 
The denied test is not a covered benefit at this time. Based on this information, we decided that Medicare rules 
for coverage of the test have not been met. Therefore, we decided that the Plan does not have to pay for the CX 
Bladder Detect test provided to the enrollee on February 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiofrequency ablation for sacro-iliac joint pain provided on 
August 9, 2021. 
 
You asked the Plan to pay for radiofrequency ablation for sacro-iliac joint pain. You say that radiofrequency 
ablation for sacro-iliac joint pain was medically necessary. The Plan denied your request. The Plan says 
radiofrequency ablation for sacro-iliac joint pain is not medically necessary based on the Medicare LCD. 
 
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 pay for radiofrequency ablation for sacro-iliac joint 
pain. Our reviewer says that radiofrequency ablation for sacro-iliac joint pain is not considered medically 
reasonable and necessary. Our physician reviewer found that according to the literature, sacral lateral nerve 
branch blocks and/or ablations/neurotomies for the diagnosis and/or treatment of sacroiliac joint mediated pain 
is considered experimental and investigational. Per CMS NCD, surgically induced lesions of nerve tracts which 
involve destruction of nerve tissue are primarily indicated for controlling the chronic or acute pain arising from 
conditions such as terminal cancer or lumbar degenerative arthritis. Radiofrequency ablation for denervation, 
whether performed using traditional, cooled, or pulsed radiofrequency, is considered investigational and 
therefore, not medically necessary. The review has determined that the requested SI joint RFA is 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 radiofrequency ablation for sacro-iliac joint pain have not been met. Therefore, 
we decided that the Plan does not have to pay for radiofrequency ablation for sacro-iliac joint pain provided on 
August 9, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve botulinum toxin (Botox) injections. 
 
You asked the Plan to pre-approve Botox. You say that the enrollee has a poorly compliant bladder. The Plan 
denied your request. The Plan says the enrollee has not tried an anticholinergic medication for overactive 
bladder symptoms. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
 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 Botox. Our physician reviewer found 
that the enrollee has a diagnosis of overactive bladder. Botox injections at a dose of 300 units every 6 months 
have been requested. Botox injections are Food and Drug Administration-approved for overactive bladder in a 
female but only at a dose of 100 units and no sooner than 12 weeks from the prior bladder injection. The 
requested dose is not supported by one of the major drug compendia or by clinical research that appears in a 
CMS-approved medical journal. The request is not listed as not indicated, not supported or not recommended 
in any of the compendia. The documentation does not support that the requested drug is safe and effective and 
otherwise reasonable and necessary for this 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 Botox have not been met. Therefore, we decided that the Plan does not have to 
pre-approve botulinum toxin (Botox) injections.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for x-ray services (73130, 73110) provided on February 9, 2022 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for out-of-network x-rays. You say that the enrollee does not have a choice in who 
reads their diagnostic tests. The Plan denied your request. The Plan says out-of-network care is only covered in 
certain limited circumstances. The requested x-rays were not urgent or emergent, nor were they pre-approved. 
These services could have been received from an in-network provider. 
 
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 x-ray services (73130, 73110) provided on 
February 9, 2022 by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gel One. 
 
You asked the Plan to pre-approve Gel One. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the requested drug does not meet step therapy criteria. 
 
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 Gel One. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has osteoarthritis of the knee. The provided records do not indicate that the enrollee has tried 
and failed Orthovisc, and Synvisc or Synvisc One. The documentation does not support that he enrollee has a 
contraindication to, or would have an adverse effect to Orthovisc, and Synvisc or Synvisc One. Therefore, the 
enrollee does not meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gel One have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gel One.
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 intensive rehabilitation, and your wife is 
unable to care for you at home. The Plan denied your request. The Plan says based on Medicare guidelines, the 
requested IRF services do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. 
 Our physician reviewer found that you are medically stable and do not need physical medicine and 
rehabilitation physician's supervision 3 times per week (at a minimum) for the ongoing management of any 
active or acute exacerbation of chronic medical conditions. You have no acute rehabilitation nursing needs 
identified or documented. At your current functional level, you do not need intensive therapies consisting of at 
least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach in an IRF. An IRF 
admission is not medically necessary based on lack of medical complexity and acute rehab nursing needs and 
high functional level. While you may benefit from continued physical therapy and occupational therapy, your 
rehabilitation needs can be safely provided in a lower intensity and alternate 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 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that the member is receiving appropriate in-patient acute care and 
does not require transfer to an LTACH. 
 
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. The patient 
appears to be more stable and improving and should only require short-term additional acute care services that 
can be safely administered at the current facility until more appropriate for a lower level of care. The patient 
does not require services at the LTACH that are not already available at the current facility. Our physician 
reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve self-administered drugs received from January 14, 2022, 
to January 18, 2022. 
 
You asked the Plan to pre-approve the drugs. You say that the denied hospital claim charges should be 
reconsidered. The Plan denied your request. The Plan says payment is not allowed based on Medicare 
guidelines. 
 
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 self-administered drugs 
received from January 14, 2022, to January 18, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (63048-59) provided on January 12, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says modifier -59 is not 
supported. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
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 the services Our reviewer says that the use 
of modifier -59 is not supported by the records provided. Our physician reviewer found that the oerative report 
describes a decompression and laminectomy at the same levels, and therefore this procedure would not be 
reported separately. Modifier -59 is not supported. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for the services (63048-59) provided on January 12, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71045 billed for date of service March 28, 
2022. 
 
You asked the Plan to pay for procedure code 71045. You say that the enrollee had multiple exams on this date, 
and this service is supported as billed. The Plan denied your request. The Plan says payment for code 71045 is 
bundled into payment for code 74022. 
 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 71045 
is a column II code to column I code 74022. 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 71045 billed for date of service March 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Image Guided Radiation Therapy (IGRT) (G6001). 
 
You asked the Plan to pre-approve IGRT. You say that the requested radiation therapy is medically necessary. 
The Plan denied your request. The Plan says the requested radiation therapy does not meet 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 IGRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the treatment itself is not disputed in this case but rather the need for image guidance. Usually, 
IGRT is used when critical structures are abutting or in close proximity to the target that is being treated to high 
doses. This situation does not apply to the enrollee for which the target lesion can be seen on the skin to assist 
in daily set up. When treating skin cancers, there is generally not a need for IGRT unless deep structures are 
being treated. Certainly using ultrasound on a daily basis is not unreasonable, but to bill for daily simple 
simulations and/or IGRT for a technology for which need has not been established by published data or 
supported by consensus guidelines (many of which recommend against treatment with these devices in general- 
citations below), billing for IGRT would not be furnished in accordance with accepted standards of medical 
practice and does not meet the LCD criteria for IGRT which specifies clinical situations for which it would be 
necessary and does not included SRT for skin cancers. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IGRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Image Guided Radiation Therapy (IGRT) (G6001).