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

 
We decided that the Plan does not have to pre-approve the Aurora Spine ZIP MIS Interspinous Fusion device. 
 
You asked the Plan to pre-approve the Aurora Spine ZIP MIS Interspinous Fusion device. You say that the 
denial is unwarranted and unsupported by the enrollee's current medical status and is inconsistent with 
currently accepted medical practice. The Plan denied your request. The Plan says the use of the requested 
device as a stand-alone procedure has not been shown to be safe and effective in long term studies. The Plan 
says that the requested device is not approved for use in a stand-alone procedure as requested by the enrollee's 
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 Aurora Spine ZIP MIS Interspinous 
Fusion device. Our reviewer says that the Aurora Spine ZIP MIS Interspinous Fusion device is not considered 
medically reasonable and necessary in this case. Our physician reviewer found the Aurora Spine ZIP MIS 
Interspinous Fusion device is experimental, and more research is needed. 
 
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 Aurora Spine ZIP MIS Interspinous Fusion device have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the Aurora Spine ZIP MIS Interspinous 
Fusion device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visit (99212) provided on August 8, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the appointment was scheduled as a 6 month follow 
up to the surgery you had when you had coverage under a different insurance carrier. The Plan denied your 
request. The Plan says enrollees must receive their medical services from an in-network provider with the 
exception being urgent or emergent services. Non-emergent services with non-contracted providers require 
prior authorization before services being rendered. 
 
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 the outpatient office visit (99212) provided on 
August 8, 2022, by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 30, 2022, to 
February 28, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from January 30, 2022, to 
February 28, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia (J0897). 
 
You asked the Plan to pre-approve Prolia. You say that this drug is medically necessary for the enrollee. The 
Plan denied your request. The Plan says the enrollee has not tried and failed the preferred drug, zoledronic acid. 
 
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 the step 
therapy criteria have not been met. Our physician reviewer found the provided documentation does not indicate 
that the enrollee has tried and failed the preferred drug. The reviewer found that there is no indication that the 
plan's required drug would likely be less effective and/or likely have adverse effects for the enrollee. Therefore, 
the reviewer found that the step therapy criteria have not been 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 Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia (J0897).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing home services provided on September 09, 2022. 
 
You asked the Plan to pay for nursing home services. You say that this was medically necessary and should be 
covered. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). there was no preauthorization by a primary care provider (this is different than a referral) for an out-of-network (OON) provider or facility, and this was not an emergency. Therefore, we 
decided that the Plan does not have to pay for nursing home services provided on September 09, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Reclast. 
 
You asked the Plan to pre-approve Reclast. The Plan denied your request. The Plan says the enrollee does not 
have a contraindication to oral bisphosphonate. 
 
 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 Reclast. Our physician reviewer found 
that the enrollee has a medical history of osteoporosis. The Plan requires a trial of oral bisphosphonate before 
they will approve the requested drug. In this case, the enrollee has not tried and failed the required drug. There 
is no documentation provided indicating that the Plans required drug 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 Reclast have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Reclast.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88360, 88341, 88342 and 88381 billed for 
date of service January 15, 2022. 
 
You asked the Plan to pay for procedure code(s) 88360, 88341, 88342 and 88381. You say that these services 
were necessary and were reported correctly. The Plan denied your request. The Plan says this code is included 
in the facility payment and is not separately payable. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88360, 88341, 88342 
and 88381. This means there is both a professional and technical component for the CPT code(s). In this case, 
an appropriate modifier to indicate the professional component has not been billed with CPT code(s) 88360, 
88341, 88342 and 88381. Based on this information, we decided that Medicare rules for coverage of procedure 
code 88360, 88341, 88342 and 88381 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code(s) 88360, 88341, 88342 and 88381 billed for date of service January 15, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ongentys. 
 
You asked the Plan to pre-approve Ongentys. You say that the requested drug is medically necessary. You say 
that the enrollee has tried and failed multiple other medications. The Plan denied your request. The Plan says 
Ongentys is a self-administered drug and does not fall under Part B coverage. The Plan says that they do not 
administer pharmacy benefits for this enrollee. 
 
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 Ongentys.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service June 29, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the enrollee had multiple exams on the date 
in question. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service June 29, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia (J0897). 
 
You asked the Plan to pre-approve Prolia. You say that the requested drug is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee has not tried and failed the preferred drug, 
zoledronic acid. 
 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 the step 
therapy criteria have not been met. Our physician reviewer found the provided documentation does not indicate 
that the enrollee has tried and failed the required drug. The reviewer found that there is no indication that the 
plan's required drug would likely be less effective and/or likely have adverse effects for the enrollee. Therefore, 
the reviewer found that the step therapy criteria have not been 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 Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia (J0897).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 77067 and 77063 billed for date of service 
June 3, 2022. 
 
You asked the Plan to pay for procedure codes 77067 and 77063. You say that this service was medically 
necessary. The Plan denied your request. The Plan says the number of units billed exceeds the maximum 
allowed.  
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 77067 and 77063 is 1. The MAI value for this code is 2. You billed 2 units 
of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure codes 77067 and 77063 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure codes 77067 and 77063 billed for date of service June 3, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service June 23, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says payment for code 70450 is bundled into 
payment for code 70496. 
 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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service June 23, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation of the thyroid. 
 
You asked the Plan to pre-approve radiofrequency ablation of the thyroid. You say that this procedure is 
medically reasonable and necessary for your condition. The Plan denied your request. The Plan says the 
requested procedure is not medically 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 radiofrequency ablation of the thyroid. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the record indicates that the enrollee has an asymptomatic benign 
thyroid nodule. There is insufficient literature to support the safety and efficacy, as defined by Medicare rules, 
for the enrollee's clinical condition. The record provided does not establish the medical necessity and 
reasonableness, as defined by Medicare rules of the requested service. The elements of the coverage criteria are 
not satisfied. 
 
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 of the thyroid have not been met. Therefore, we 
decided that the Plan does not have to pre-approve radiofrequency ablation of the thyroid.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on June 27, 2022. 
 
You asked the Plan to pay for the lab services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says you billed with an incorrect place of 
service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on June 27, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for PET scan provided on July 27, 2022. 
 
You asked the Plan to waive the copayment for PET scan. You say that this should be covered. The Plan 
denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $300 
copayment for PET scan. 
 
You have been asked to pay a $300 copayment for PET scan. This item/service falls within the PET scan 
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 PET scan provided on July 27, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650) provided March 30, 2022. 
 
You asked the Plan to pay for the orthosis. You say that please see attached medical documentation that meets 
all criteria to support medical necessity including Doctor's signed order, physician notes and proof of delivery. The Plan denied your request. The Plan says medical necessary cannot be determined as missing the medical 
record for this service. 
 
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 the orthosis. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found based on the medical records provided there is no documentation that the lumbar-sacral orthosis 
(L0650) at issue in this case meets all Medicare criteria for medically reasonable and necessary. The provided 
medical records do not document a need for the orthosis to reduce pain by restricting mobility of the trunk; or 
to facilitate healing following an injury to the spine or related soft tissues; or to facilitate healing following a 
surgical procedure on the spine or related soft tissue; or to otherwise support weak spinal muscles and/or a 
deformed spine, as required by the LCD. 
 
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 orthosis have not been met. Therefore, we decided that the Plan does not 
have to pay for the lumbar-sacral orthosis (L0650) provided March 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal cord stimulator. 
 
You asked the Plan to pre-approve the stimulator. You say that this is medically necessary. The Plan denied 
your request. The Plan says this 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 stimulator. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the enrollee does not have an evidence-based indication for a spinal cord stimulator trial. 
The psychological evaluation shows limited understanding of the proposed device as well as significant 
depression and anxiety. The request is not medically reasonable and 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 stimulator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a spinal cord stimulator.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gammagard. 
 
You asked the Plan to pre-approve Gammagard. You say that the records provided support the need for the 
requested services. The Plan denied your request. The Plan says the enrollee is stable without Gammagard and 
IVIG is not indicated in stable Myasthenia gravis. 
 
The Plan follows Medicare rules. Medicare rules say that routine use of Immune Globulins for treatment of 
Myasthnia gravis (MG) is not indicated. 
 
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 Gammagard. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found there is no documentation that the 
Gammagard at issue in this case meets all Medicare criteria for medically reasonable and necessary and safe 
and effective for the patient. The most recent available records document the patient is "doing well" with no 
diplopia, dysphagia or changes in speech. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gammagard have not been met.  
 
 
 
  
Therefore, we decided that the Plan does not have to pre-approve Gammagard.