Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the routine ophthalmological examination including 
refraction (S0621) provided on October 5, 2022. 
 
You asked the Plan to pay for the routine ophthalmological examination. You say that you would like at least 
the allowed amount to be paid for this service. The Plan denied your request. The Plan says this benefit had 
been exhausted. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers one routine eye exam per calendar year. 
 
We looked at the file and the Plan's rules. The record shows that you received a comprehensive routine eye 
exam (92014) on October 5, 2022, and your routine eye exam benefit had been exhausted. Based on this 
information, we decided that the Plan's rules for coverage of the routine ophthalmological examination have 
not been met. Therefore, we decided that the Plan does not have to pay for the routine ophthalmological 
examination including refraction (S0621) provided on October 5, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99601 billed for date of service January 18, 
2022. 
 
You asked the Plan to pay for procedure code 99601. You say that this service is a covered medical benefit for 
implanted pain pumps and all services pertaining to them. You also say that this is a medical service, not 
pharmacy, and is not misrouted. The Plan denied your request. The Plan says the billed code is invalid for 
Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
 
  We find that procedure code 99601 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 99601 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 99601 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99601 billed for date of service January 18, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the outpatient left total knee arthroplasty (TKA) 
(27447). 
 
You asked the Plan to pre-approve the outpatient surgery. You say that see the attached additional clinical for 
the enrollee's upcoming surgery for a left TKA. The Plan denied your request. The Plan says the outpatient left 
total knee replacement 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 the outpatient surgery. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee was being treated for osteoarthritis of the left knee and presented with 
knee pain that is interfering with quality of life and affecting activities of daily living. However, detailed 
documentation is not evident regarding a trial and failure of recent, reasonable, comprehensive less invasive 
conservative care measures including a full course of formal physical therapy. Additionally, the documentation 
does not include height, weight, and/or body mass index. 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. Therefore, the requested outpatient left total knee replacement, 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 outpatient surgery have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the outpatient left total knee arthroplasty (TKA) (27447).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Aurora Spine ZIP MIS interspinous fusion device 
(22612, 22840). 
 
You asked the Plan to pre-approve the surgical procedure. You say that the requested procedure is medically 
necessary. The Plan denied your request. The Plan says this device as a stand-alone procedure has not been 
shown to be safe and effective in long term studies. This device is not approved for use in a stand-alone 
procedure as requested by your pain practitioner provider. 
 
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 the enrollee was being treated for spinal stenosis of the lumbar region with 
neurogenic claudication. The exam reveals bilateral paraspinal muscle spasms with tenderness over the lumbar, 
lumbosacral, and sacroiliac joints. There is a diminished sensation in the lateral leg. However, there is limited 
published, large-scale, long-term peer-reviewed literature that shows this requested interspinous device to be an 
effective and/or safe treatment for the noted pathology. Further studies are needed to demonstrate this request has beneficial outcomes compared with conventional treatment. There is no compelling rationale presented or 
extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the 
requested Aurora ZIP MIS interspinous fusion device, 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 Aurora Spine ZIP MIS interspinous fusion device (22612, 22840).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on November 3, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that at this time, there is no 
contractual agreement which indicates that these tests should be included in the dialysis rate. The Plan denied 
your request. The Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
November 3, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the take-home supply of methadone (G2078) provided on 
October 3, 2022. 
 
You asked the Plan to pay for the take-home supply of methadone. You say that you believe the Plan did not 
have all the necessary information to process this claim correctly. The Plan denied your request. The Plan says 
payment is not allowed for this claim because it does not meet the opioid treatment program criteria for 
payment. 
 
The Plan must follow Medicare rules. Medicare Part B coverage is available for outpatient Opioid Treatment 
Program (OTP) services provided by hospitals, Critical Access Hospitals (CAHs), and Free-Standing Opioid 
Treatment Program facilities. The rules say that only an entity enrolled with Medicare as an OTP can bill these 
codes. 
 
 
  We looked at the file and Medicare rules. The claim was billed by the rendering provider and not an OTP 
facility. Individual providers cannot bill for OTP services. Based on this information, we decided that Medicare 
rules for coverage of the take-home supply of methadone have not been met. Therefore, we decided that the 
Plan does not have to pay for the take-home supply of methadone (G2078) provided on October 3, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that due to health issues you need to be able to sit 
down during a shower. The Plan denied your request. The Plan says this item is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99211 billed for date of service September 6, 
2022. 
 
You asked the Plan to pay for procedure code 99211. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 99211 is bundled into payment for code 96372. 
 
 
 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 99211 
is a column II code to column I code 96372 with a modifier indicator of 0. 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 procedure code 99211 billed for date of service September 6, 2022.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medication assisted treatment provided on October 10, 
2022. 
 
You asked the Plan to pay for the medication assisted treatment. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services billed are not payable. 
 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 code G2067 is medication assisted treatment, methadone; 
weekly bundle including dispensing and/or administration, substance use counseling, individual and group 
therapy, and toxicology testing, if performed (provision of the services by a Medicare-enrolled opioid treatment 
program). 
 
We find that CPT code G2067 is not supported in the medical record. Specifically, payment is not allowed for 
this claim because this service does not meet the opioid treatment program criteria for payment. Payment can 
only be made for opioid treatment program claims for staffing, availability and accessibility of services, care 
coordination, scope of services, quality and other reporting, and organizational authority (SAMHSA) criteria 
providers. Review of the file does not support that the provider meets this program criteria. Based on this 
information, we decided that Medicare rules for coverage of the medication assisted treatment have not been 
met. Therefore, we decided that the Plan does not have to pay for the medication assisted treatment provided on 
October 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve addition to lower extremity, above knee or knee 
disarticulation, acrylic socket (L5631). 
 
You asked the Plan to pre-approve the item. You say that this is medically necessary. The Plan denied your 
request. The Plan says based on the additional information available, the request does not meet the Medicare or 
health plan coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that L5631 is not covered when L5590 is provided.  
 
The case file shows that L5590 was approved in this case. Therefore, L5631 cannot be approved. Based on this 
information, we decided that Medicare rules for coverage of the item have not been met. Therefore, we decided 
that the Plan does not have to pre-approve addition to lower extremity, above knee or knee disarticulation, 
acrylic socket (L5631).
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Evenity. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says that the enrollee has not tried and failed the preferred step therapy alternatives. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan states that the enrollee has not tried and failed the Plan's step therapy 
alternative; however, no medical records were submitted. Without medical records, it cannot be determined if 
the enrollee has tried and failed the step therapy drug or that the preferred drug would be contraindicated or less 
effective. Therefore, we decided that the Plan has to pre-approve Evenity.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting reconsideration for the denial of 
an IRF admission based on medical necessity. The Plan denied your request. The Plan says the request for IRF 
services does 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 the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical and/or occupational therapy, there is no documented need for 
intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is 
not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 
 
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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve oncology physician services to be provided by an out-
of-network (OON) provider. 
 
You asked the Plan to pre-approve oncology physician services. You say that you wish to follow your provider 
to the provider's new OON practice. The Plan denied your request. The Plan says rules for coverage for OON 
care have not been met. 
 
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 
oncology physician services to be provided by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visits (99213) and the acupuncture treatments 
(97813, 97814) provided from June 14, 2021, through June 19, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services are not payable as they were 
rendered by an ineligible provider. 
 The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the acupuncture services in this case were not 
rendered under the supervision of a physician, physicians assistant, nurse practitioner, or clinical nurse 
specialist. Therefore, we decided that the Plan does not have to pay for the office visits (99213) and the 
acupuncture treatments (97813, 97814) provided from June 14, 2021, through June 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic manipulative treatments (98940 x 2) and the 
extraspinal chiropractic manipulative treatments (98943 x 2) provided on November 29, 2022 and  
December 13, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services provided are not a covered benefit 
by Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover chiropractic maintenance 
care. The rules also say that the only covered chiropractic service is manual manipulation of the spine to correct 
a subluxation.  
 
We looked at this case file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of these services have not been met. Specifically, the chiropractic manipulative treatments provided 
in this case are considered maintenance therapy as billed. Maintenance therapy is not a covered benefit. 
Additionally, Medicare rules state that the only covered chiropractic service is manual manipulation of the 
spine to correct a subluxation; therefore, the extraspinal chiropractic manipulative treatments are not covered.   Therefore, we decided that the Plan does not have to pay for the chiropractic manipulative treatments  
(98940 x 2) and the extraspinal chiropractic manipulative treatments (98943 x 2) provided on November 29, 
2022 and December 13, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Stelara. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says self-administered drugs are not covered. 
 
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 Stelara.  
 
Benefits for these services 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 a lumbar-sacral orthosis (L0631) to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a lumbar-sacral orthosis. You say that the requested item is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for OON services 
have not been met. 
 
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 
a lumbar-sacral orthosis (L0631) to be provided by an OON provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71045 billed for date of service September 
28, 2022. 
 
You asked the Plan to pay for procedure code 71045. You say that the claim was billed correctly and should be 
paid. The Plan denied your request. The Plan says payment for code 71045 is bundled into payment for code 
32557. 
 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 32557. 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 September 28, 
2022.