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

 
We decided that the Plan does not have to pay for the medication assisted treatment billed with code G2067 for 
December 5, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed by an OTP. 
 
The Plan must follow Medicare rules. The rules say that only an entity enrolled with Medicare as an opioid 
treatment program (OTP) can bill codes G2067-G2075, G2076-G2080, G2215, G2216, and G1028. 
 
We looked at the file and Medicare rules. The file shows that code G2067 was not billed by a provider enrolled 
as an OTP. Therefore, we decided that the Plan does not have to pay for the medication assisted treatment 
billed with code G2067 for December 5, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the intracept procedure. 
 
You asked the Plan to pre-approve the intracept procedure. You say that the service is medically necessary. The 
Plan denied your request. The Plan says this service is considered experimental. 
 
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 intracept procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the cause of back pain for this patient is unclear. 
 
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 intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the intracept procedure.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from February 19, 2022, 
to February 27, 2022. 
 You asked the Plan to pay for the home health services as billed. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as 
billed. 
 
The Plan follows Medicare rules. The rules say that providers must report services correctly. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, revenue 
code 0023 was not submitted correctly per Medicare guidelines. Therefore, we decided that the Plan does not 
have to pay for the home health services provided from February 19, 2022, to February 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on May 12, 2022. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says that the 
member's Plan excludes coverage for this out-of-network service. 
 
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 May 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99152 billed for November 17, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 99152 is not supported. 
 
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 99152 is moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 
5 years or older. 
 
We find that CPT code 99152 is not supported in the medical record. Specifically, the records show that moderate sedation services provided by the same physician or qualified health care professional providing a 
gastrointestinal endoscopic service were performed and there is a more appropriate code for these services. 
Based on this information, we decided that Medicare rules for coverage of these services have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 99152 billed for November 17, 
2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Bupivacaine (J3490) provided on November 18, 2022. 
 
You asked the Plan to pay for the Bupivacaine. The Plan denied your request. The Plan says Bupivacaine is a 
local anesthetic agent that cannot be separately reimbursed. 
 
The Plan must follow Medicare rules. Medicare rules say that the Medicare Fee Schedule Data Base (MFSDB) 
provides the postoperative periods that apply to each surgical procedure. If there is an indicator of 000, 
postoperative visits beyond the day of the procedure are not included in the payment amount for the surgery.  
 
 
 We looked at the file and Medicare rules. The record shows that the enrollee had epidural steroid injections 
(codes 64483 and 64484) performed on November 18, 2022. The MFSDB shows that the postoperative period 
for these codes is the day of the surgery/procedure. The enrollee received the Bupivacaine (J3490) on 
November 18, 2022, which is the same day the initial procedure was rendered. Therefore, this procedure is 
bundled as part of the global surgical fee because it was reported the same day as the epidural steroid injections 
(codes 64483 and 64484). Therefore, we decided that the Plan does not have to pay for the Bupivacaine 
(J3490) provided on November 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sacroiliac joint radiofrequency ablation (RFA) services.

You asked the Plan to pre-approve the sacroiliac joint RFA services. You say that the records provided support the need for the RFA services in dispute. The Plan denied your request. The Plan says sacroiliac joint injections are not considered reasonable and 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 sacroiliac joint RFA services.

Our reviewer says that the sacroiliac joint RFA services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has a history of chronic low back pain due to sacroiliitis. He has been treated with medications, physical therapy, chiropractic care, a home exercise program, and bilateral sacroiliac joint injections. 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. Radiofrequency ablation for denervation, whether performed using traditional, cooled, or pulsed radiofrequency, is considered investigational and therefore, not medically 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 sacroiliac joint RFA services have not been met. Therefore, we decided that the Plan does not have to pre-approve sacroiliac joint radiofrequency ablation (RFA) services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the intracept procedure. 
 
You asked the Plan to pre-approve the intracept procedure. You say that the service is medically necessary. The 
Plan denied your request. The Plan says this service is considered experimental. 
 
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 intracept procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this service is considered experimental. 
 
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 intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the intracept procedure.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 You asked the Plan to pre-approve Prolia. You say that this drug is medically necessary. The Plan denied your 
request. The Plan says a trial of Zoledronic acid is required before alternatives can be considered. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Prolia. Our reviewer says that Prolia is 
not medically necessary. Our physician reviewer found the records do not show a trial of the plan preferred 
drugs or any reason they would be unsafe or ineffective. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xgeva. 
 
You asked the Plan to pre-approve Xgeva. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
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 Xgeva. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has a diagnosis of age-related osteoporosis without current pathological fracture. The Food 
and Drug Administration has not stated that the requested drug formulation is indicated for the enrollee's 
condition. The Medicare approved drug compendia do not contain a supportive citation for the use of the 
requested drug formulation in the enrollee's clinical situation. 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 Xgeva have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Xgeva.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for a mammography (code 77049) provided on May 3, 2022. 
 
You asked the Plan to pay for the mammography. You say that the services were medically necessary. The 
Plan denied your request. The Plan says that charges for or in connection with services or supplies that are, as 
determined by us, considered to be experimental or investigational are excluded from coverage under the 
member's Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not provided a Medicare rule, a Plan rule or a coding 
rule to substantiate their denial. Therefore, we decided that the Plan has to pay for a mammography  
(code 77049) provided on May 3, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and 
compression sleeves (E0667, E0668). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that the item is medically 
necessary. The Plan denied your request. The Plan says there is no evidence of a four-week trial of 
conservative therapy demonstrating failed response to treatment with an 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 compression sleeves (E0667, E0668).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for stimulator supplies (A4595) provided on November 27, 
2022. 
 
You asked the Plan to pay for the stimulator supplies. You say that this item was medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed items. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. The records provided make no mention of the need for this equipment nor do they document how it 
would be used. The record shows that the Plan made several attempts to obtain the necessary documentation 
without success. Therefore, we decided that the Plan does not have to pay for stimulator supplies (A4595) 
provided on November 27, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex Superion Interspinous device (22869). 
 
You asked the Plan to pre-approve the Vertiflex Superion Interspinous device. You say that the service is 
medically necessary. The Plan denied your request. The Plan says this device is considered experimental. 
 
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 Vertiflex Superion Interspinous 
device. Our reviewer says that the requested item is not considered medically reasonable and necessary in this 
case. Our physician reviewer found this device is considered experimental. 
 
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 Vertiflex Superion Interspinous device have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the Vertiflex Superion Interspinous device (22869).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sleep comfort mattress. 
 
You asked the Plan to pre-approve the requested mattress. You say that you have chronic fatigue. The Plan 
denied your request. The Plan says the mattress is 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 requested mattress 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. Therefore, we decided that the 
Plan does not have to pre-approve a sleep comfort mattress.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Leqvio (inclisiran) injections. 
 
You asked the Plan to pre-approve the requested Leqvio treatments. You say that Leqvio would be preferable 
to other agents as it involves fewer injections. The Plan denied your request. The Plan says the enrollee is able 
to self-inject and has not failed a PCSK9 inhibitor drug (such as Repatha). 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
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 treatments. Our 
reviewer says that the requested Leqvio treatments are not shown to be medically necessary. Our physician 
reviewer found inclisiran [Leqvio] is indicated as an adjunct to diet and maximally tolerated statin therapy to 
treat adults with clinical atherosclerotic cardiovascular disease (ASCVD) or heterozygous familial 
hypercholesterolemia (HeFH) who require additional lowering of low-density lipoprotein-C (LDL-C). Provided 
medical records in this case document that the patient is currently on 5 mg of rosuvastatin daily "as he cannot 
go up any higher on this without marked side effects." The prescriber's reported plan is to "stop his rosuvastatin 
and place him on Leqvio." The plan to stop a tolerated statin and to start Leqvio is not consistent with the Food 
and Drug Administration-approved labeled use of Leqvio. As such, Medicare criteria for medically reasonable and necessary are not met.  
 
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 treatments have not been met. Therefore, we decided that 
the Plan does not have to pre-approve Leqvio (inclisiran) injections.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve injections (64454). 
 
You asked the Plan to pre-approve the injections. You say that you would like to file an appeal because you 
were denied surgery on your knee for the fifth time. The Plan denied your request. The Plan says there is not 
enough evidence to show that this procedure is safe, and it works well for knee pain. 
 
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 injections. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found when an individual exhibits knee pain, the pain signals can be generated from the peripheral 
nerves innervating the knee, including several branches of the genicular nerve. A diagnostic genicular nerve 
block consists of placing a small amount of local anesthetic on the genicular nerves to determine if there is sufficient pain relief in the knee to justify performing a therapeutic neurotomy. Radiofrequency ablation of the 
genicular nerves is then performed to restore function and alleviate knee pain. Genicular nerve blocks and 
genicular nerve ablation are investigational and/or unproven for the treatment of osteoarthritis of the knee The 
review has determined that the items/services at issue in this case are 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 injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve genicular nerve injections (64454).
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 October 10, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that at this time, there is no 
contractual agreement that indicates that these tests are 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 October 
10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99232 and 99223 billed for August 23, 
2022, and August 25, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the billed diagnosis code is not appropriate. 
 
The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis 
code. 
 
We looked at the file and Medicare rules. The file shows that the services were not billed with an appropriate 
primary diagnosis code. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 
99232 and 99223 billed for August 23, 2022, and August 25, 2022.