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

 
We decided that the Plan does not have to pre-approve Rinvoq (J8499). 
 
You asked the Plan to pre-approve Rinvoq. You say that this is medically necessary for the enrollee's condition. 
The Plan denied your request. The Plan says this drug is not covered under the enrollee's medical benefit. 
 
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 Rinvoq (J8499).  
 
Benefits for Rinvoq 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6533. 
 
You asked the Plan to pre-approve the compression stockings. You say that you disagree with the denial. The 
Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6533 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6533.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat epidural steroid injection. 
 
You asked the Plan to pre-approve a repeat epidural steroid injection. You say that a repeat epidural steroid 
injection is medically necessary. The Plan denied your request. The Plan says the documentation confirms that 
three months have not passed since the first epidural steroid injection (March 22, 2022), and the medical record 
does not document at least 50% of sustained improvement in pain relief and/or improvement in function 
measured from baseline. 
 
The Plan follows Medicare rules. Medicare rules say that a repeat ESI when the first injection directly and 
significantly provided improvement of the condition being treated may be considered medically reasonable and 
necessary when the medical record documents at least 50% of sustained improvement in pain relief and/or 
improvement in function measured from baseline using SAME scale* for at least three months.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a repeat epidural steroid injection. Our 
reviewer says that a repeat epidural steroid injection is not medically necessary. Our physician reviewer found 
the Medicare criteria requires a 3-month improvement in pain. The medical records show that your pain relief 
lasted only 3 days. Therefore, the request is considered 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 a repeat epidural steroid injection have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a repeat epidural steroid injection.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services to be provided by 
an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve SNF services. You say that the member is not at baseline. The Plan denied 
your request. The Plan says that the enrollee does not have out of network coverage. 
 
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 skilled nursing facility (SNF) services to be 
provided by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care, per day (99308) provided 
on November 29, 2021. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that the enrollee received care from 
multiple providers on the date in question. The Plan denied your request. The Plan says this service is included 
in the payment for 99309, which was billed for the same enrollee on the same date and was rendered by a 
provider in the same facility with the same specialty as the service at issue. 
 
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 99308 
is a column II code to column I code 99309 with a modifier indicator of 0. Although these services were billed 
by two different providers, the providers have the same specialty/taxonomy codes and are part of the same facility. The column II code is therefore not payable. Based on the claim submitted, Medicare billing criteria 
have not been met. Therefore, we decided that the Plan does not have to pay for subsequent nursing facility 
care, per day (99308) provided on November 29, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a panniculectomy. 
 
You asked the Plan to pre-approve a panniculectomy. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not 
covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are 
coverable.   
 
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 panniculectomy. Our reviewer says 
that the documentation does not support that the requested services are medically reasonable or necessary. Our 
reviewer found the enrollee lost weight after bariatric surgery. The record does not indicate that the enrollee 
has a pannus that extends beneath the pubis symphysis or that causes functional limitations. The record 
indicates that powder controls rashes do not document the presence of intertrigo that is unresponsive to 
conservative medical management. Therefore, the enrollee does not meet criteria for the requested 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 a panniculectomy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a panniculectomy.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) to the lumbar spine 
bilaterally at L5 (CPT code(s): 64636, 64635). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says the requested procedure is supported if the enrollee's pain is localized to either their neck 
or back and DOES NOT travel to other areas of their body. The Plan states the documentation shows the 
enrollee with pain that can at times radiate through the left buttock, into the left lateral aspect of their leg". 
 
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 services. Our physician reviewer 
found only one set of diagnostic MBBs is documented.  Therefore, until a second confirmatory set is 
performed, 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve radiofrequency ablation (RFA) to the lumbar spine bilaterally at L5 (CPT code(s): 64636, 
64635).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve excision, excessive skin and subcutaneous tissue 
(includes lipectomy); abdomen, infraumbilical panniculectomy (CPT code 15830). 
 
You asked the Plan to pre-approve the service. You say that if the enrollee does not receive the procedure, their 
health could decline faster. The Plan denied your request. The Plan says the enrollee's request is not medically 
necessary because their records show the enrollee does not have skin problems due to their pannus and the 
enrollee is not having disabling symptoms. 
 
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 service. Our physician reviewer 
found the record indicates that the enrollee has had weight gain. The record does not indicate the presence of 
intertrigo or other skin issues that are refractory to conservative medical treatment. The record does not indicate 
the presence of functional disability from the pannus. The record provided does not support the medical 
necessity, as defined by Medicare rules of the requested procedure. 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 the service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen, 
infraumbilical panniculectomy (CPT code 15830).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sure hands body support and sure hands thigh support 
accessories for a ceiling lift. 
 
You asked the Plan to pre-approve sure hands body support and sure hands thigh support accessories for a 
ceiling lift. You say that you would like the plan to reconsider their denial. The Plan denied your request. The 
Plan says the requested items are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
 
 The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. In addition, the 
ceiling lift was purchased by the enrollee and was not approved and purchased by the Plan. Since the ceiling 
lift was not approved by the Plan, the accessories for this item are also not covered. Therefore, we decided that 
the Plan does not have to pre-approve sure hands body support and sure hands thigh support accessories for a 
ceiling lift.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on October 6, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the service was medically necessary and you like 
reconsideration with the records. The Plan denied your request. The Plan says the rendering provider is an 
OON provider and there was no referral from an in-network provider or an approved authorization. Also, the 
service rendered was not urgent or emergent. 
 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 an office visit provided on October 6, 2021, by an 
out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for antibody identification; platelet antibodies (CPT code 86022) 
provided on September 15, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you do not understand why the Plan is 
charging you this amount. The Plan denied your request. The Plan says code 86022 denied properly for 
exceeding the number of allowed units. 
 
The Plan must follow Medicare rules. Per Medicares Medically Unlikely edits, the units of service billed for 
procedure code 86022 exceed the allowed number of units of 1 in 1 day for date of service edit: policy. 
Therefore, we decided that the Plan does not have to pay for antibody identification; platelet antibodies (CPT 
code 86022) provided on September 15, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for blood smear, peripheral, interpretation by physician with 
written report (CPT code 85060) provided on September 22, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the service is not covered as billed.  
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the laboratory services have not been met. No payment is 
recognized for code 85060 furnished to hospital outpatients or non-hospital patients. The physician 
interpretation is paid through the clinical laboratory fee schedule payment for the clinical laboratory test. The 
denied CPT code 85060 may not be paid if furnished to hospital outpatients or non-hospital patients. Review of 
the member's claim shows the provider billed in a place of service of 22- Outpatient Hospital. If the provider 
determines that a billing error occurred during the initial submission of the denied claim, the plan will accept a 
submission of a corrected claim to consider services for payment. You can find the above guidelines on the 
Medicare website at https://www.cms.gov. Therefore, we decided that the Plan does not have to pay for blood 
smear, peripheral, interpretation by physician with written report (CPT code 85060) provided on September 22, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home health visit provided on November 2, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the home health visit. You say that the facility is responsible to obtain prior 
authorization and you would like the claim reimbursed for the service that was rendered. The Plan denied your 
request. The Plan says the rendering provider is an OON provider and there was no referral from an in-network 
provider or an approved authorization. Also, the service rendered was not urgent or emergent. 
 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 a home health visit provided on November 2, 
2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse payment for the durable medical equipment (DME) 
provided on January 19, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to reimburse payment for the DME. You say that you were out of the area and your knee 
was hurting so you ordered the brace from the OON provider instead of the in-network supplier. The Plan 
denied your request. The Plan says the enrollee called on several occasion and was given and advised of in-
network providers that could supply the equipment that was needed. 
 
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 reimburse payment 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 reimburse payment for these 
items/services. Therefore, we decided that the Plan does not have to reimburse payment for the durable medical 
equipment (DME) provided on January 19, 2022, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT 
code(s): 22869 and 22870). 
 
You asked the Plan to pre-approve the device. You say that the services are necessary. The Plan denied your 
request. The Plan says the Medicare criteria for reasonable and necessary are not met as this device has not 
been shown to be safe and effective in long term studies and there is a lack of evidence to support that 
interspinous spacer devices are as safe and effective as the gold standard of decompression or other procedures 
which are available and medically appropriate alternatives. The Plan states the information submitted indicates 
that you have mild or absent canal stenosis at the levels requested for treatment which does not meet the 
indications for this device as documented by the manufacturer. The Plan states you have also had prior lumbar 
surgery and the manufacturer reports this device has not been studies in patients with prior lumbar spine 
surgery. 
 
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 device. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the requested Vertiflex Superion interspinous device at L2-3 and L3-4, 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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Vertiflex superion device placement surgery (CPT code(s): 22869 and 22870).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Durolane injections. 
 
You asked the Plan to pre-approve the Durolane injections. You say that the records provided support the need 
for the requested injection services. The Plan denied your request. The Plan says the office notes provided do 
not demonstrate that the requirements for coverage have been met. 
 
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 Durolane injections. Our reviewer 
says that Durolane injections are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has bilateral knee pain due to osteoarthritis of the knee. He reports he can hear 
"grinding" in his knees. He has not tried physical therapy. He had prior cortisone injections but reports the 
injections did not provide any pain relief. He underwent a trial of CBD oil. Knee replacement was considered 
but due to a HbA1c of 9.5, but he has been deemed not a suitable candidate for surgery.  X-rays of bilateral 
knees reported osteoarthritis. 
 
  
 His provider has recommended intra-articular injections of Durolane, both knees. According to DrugDex, a 
Medicare-approved compendium, "Hyaluronic acid is indicated for osteoarthritis pain in patients who have not 
responded to conservative nonpharmacologic therapy or to simple analgesics, such as acetaminophen." In this 
case, there is no documentation of an inadequate response to conservative therapies. 
 
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 Durolane injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Durolane injections.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dual-energy X-ray absorptiometry (DXA), bone density 
study, 1 or more sites; axial skeleton (eg, hips, pelvis, spine), including vertebral fracture assessment (CPT 
code 77085) provided on January 14, 2022. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says this is a duplicate. 
 The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the service have not been met. The documentation submitted does 
not support CPT code 77085-26, which was billed twice on January 14, 2022. The records submitted do not 
indicate that two separate services were performed/supported. CPT code 77085-26 was paid on February 24, 
2022. Therefore, we decided that the Plan does not have to pay for dual-energy X-ray absorptiometry (DXA), 
bone density study, 1 or more sites; axial skeleton (eg, hips, pelvis, spine), including vertebral fracture 
assessment (CPT code 77085) provided on January 14, 2022.