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

 
We decided that the Plan does not have to pay for the laboratory services (80324, 80332, 80335, 80346, 80348, 
80349, 80353, 80354, 80356, 80357, 80358, 80359, 80360, 80361, 80362, 80365, 80367, and 80369) provided 
on March 18, 2020. 
 
You asked the Plan to pay for the laboratory services. 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 must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code.  
We looked at the file and Medicare rules. In this case, CPT codes 80324, 80332, 80335, 80346, 80348, 80349, 
80353, 80354, 80356, 80357, 80358, 80359, 80360, 80361, 80362, 80365, 80367, and 80369 each have a status 
code of "I" under the Medicare Physicians Fee Schedule Database (MPFSDB) and these codes are not valid for 
Medicare purposes. Medicare uses other codes for reporting of, and payment for, these services. Therefore, we 
decided that the Plan does not have to pay for the laboratory services (80324, 80332, 80335, 80346, 80348, 
80349, 80353, 80354, 80356, 80357, 80358, 80359, 80360, 80361, 80362, 80365, 80367, and 80369) provided 
on March 18, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for long term acute care hospital (LTACH) services provided 
from July 27, 2020, to October 15, 2020. 
 
You asked the Plan to pay for the LTACH services. You say that the services should be covered. The Plan 
denied your request. The Plan says continued LTACH care is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the LTACH services. Our reviewer says that 
the LTACH care is not considered medically reasonable and necessary in this case.  
 Our physician reviewer found the provided documentation indicates that enrollee was receiving appropriate 
care at the present acute care hospital. The reviewer found that the enrollee did not require services at the 
LTACH that were not available at the acute care hospital where they were currently receiving care. The 
reviewer found there were no services available at the LTACH that the enrollee required that were not available 
at the health care setting being offered by the health plan. The reviewer found that the LTACH services were 
not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to 
be furnished safely and effectively only on an inpatient basis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pay for long term acute care hospital (LTACH) services provided from July 27, 2020, to 
October 15, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a walker (E0143) and seat attachment (E0156), provided on 
September 20, 2021. 
 
You asked the Plan to pay for a walker and seat attachment. You say that the item is medically necessary. The 
Plan denied your request. The Plan says there was no proof of delivery or pick-up documentation submitted. 
 
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 a valid proof of delivery, or relevant medical records which support medical 
necessity for the supplies provided in this case. 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 a 
walker (E0143) and seat attachment (E0156), provided on September 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the moderate sedation services (99152) provided on August 
24, 2021. 
 
You asked the Plan to pay for the moderate sedation services. You say that you would like reconsideration 
based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does 
not support the service billed. 
 
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 record. Specifically, the documentation submitted does 
not indicate the presence of an independent trained observer to assist in the monitoring of the patient's level of 
consciousness and physiological status. Based on this information, we decided that Medicare rules for coverage 
of the moderate sedation services have not been met. Therefore, we decided that the Plan does not have to pay 
for the moderate sedation services (99152) provided on August 24, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the dialysis services provided from July 2, 2021, to August 30, 2021 
 
You asked the Plan to pay for the dialysis services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the services are not covered as billed. 
 
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 denial does not provide sufficient specificity to determine which modifier 
the Plan is saying is incorrect or missing. Therefore, we decided that the Plan has to pay for the dialysis 
services provided from July 2, 2021, to August 30, 2021  
 
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 pay for the compression stockings identified with code A6530 that 
were issued on December 13, 2021. 
 
You asked the Plan to pay for the compression stockings. 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. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 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 pay for the compression 
stockings identified with code A6530 that were issued on December 13, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Genvisc (J7320) and the associated arthrocentesis, 
aspiration and/or injection (20610). 
 
  You asked the Plan to pre-approve Genvisc and the associated arthrocentesis, aspiration and/or injection. You 
say that the enrollee has a tear and swelling in his left knee, and needs this treatment. The Plan denied your 
request. The Plan says the enrollee does not have any stated contraindications to the preferred products. The 
enrollee has not tried any of the preferred agents. The Plan also says the provider does not provide a rationale 
for use of the non-preferred product for safety or efficacy. 
 
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 Genvisc and the associated 
arthrocentesis, aspiration and/or injection. Our reviewer says that Genvisc is not medically reasonable and 
necessary for the enrollee. Our physician reviewer found the provided documentation did not clearly show the 
patient having tried and failed Orthovisc, Synvisc, or Synvisc One. Our reviewer also found that Orthovisc, 
Synvisc, or Synvisc One would not likely be less effective and/or likely have worse adverse effects for the 
enrollee compared to the requested Genvisc, as these are all equivalent agents and have essentially the same 
safety and effectiveness based on comparative studies. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Genvisc and the associated arthrocentesis, aspiration and/or injection have not 
been met. Therefore, we decided that the Plan does not have to pre-approve Genvisc (J7320) and the associated 
arthrocentesis, aspiration and/or injection (20610).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Intravenous Immune Globulin (IVIG). 
 
You asked the Plan to pre-approve the IVIG. You say that you would like reconsideration because the 
requested IVIG is medically necessary. The Plan denied your request.  The Plan says there is no documented evidence of rapid progression of a covered disease or relapse, or when 
other forms of treatment have failed or are contraindicated. 
 
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 IVIG. Our reviewer says that you 
do not meet the LCD criteria for coverage. Our physician reviewer found the provided documentation did not 
clearly show evidence of a rapid progression of a covered disease (or relapse) or show evidence of you having 
failed or have contraindications to other forms of therapy. 
 
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 IVIG have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Intravenous Immune Globulin (IVIG).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories. 
 
You asked the Plan to pre-approve a group 3 power wheelchair and accessories. You say that this device is 
medically reasonable and necessary. The Plan denied your request. The Plan says the enrollee does not have a 
qualifying diagnosis for a group 3 power wheelchair. 
 
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for 
enrollees who have a mobility limitation that is due to: 
 
1. A neurological condition; 
 
2. Myopathy; or 
 
3. Congenital skeletal deformity. 
 
 
 The file does not show that the enrollee has a mobility limitation that is due to a neurological condition, 
myopathy or congenital skeletal deformity. Therefore, we decided that the Plan does not have to pre-approve a 
group 3 power wheelchair and accessories.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the one touch verio test strips 
 You asked the Plan to pay for the one touch verio test strips. You say that you want to be able to monitor the 
member's blood glucose levels remotely. The Plan denied your request. The Plan says there is no medical 
reason this item is needed over the Plan's preferred brands. 
 
The Plan must follow Medicare rules. Medicare rules say that MA plans may specify brands and manufacturers 
as preferred and charge lower cost-sharing for the preferred brands or may limit the Durable Medical 
Equipment (DME) to only those preferred brands and manufacturers. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the one touch verio test strips have not been met. Therefore, we decided that the Plan does not have 
to pay for the one touch verio test strips
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the facet joint injections at C7 and T1.  
You asked the Plan to pre-approve the facet joint injections at C7 and T1. You say that you would like 
reconsideration because the requested injections are medically necessary. The Plan denied your request. The 
Plan says the records do not include documentation of exam findings verifying that the enrollee's pain is likely 
due to facet pathology or documentation of conservative treatment. 
 
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 facet joint injections at C7 and T1. 
Our reviewer says that the enrollee does not meet the LCD criteria for coverage. Our physician reviewer found 
there is no physical exam of the neck which includes facet loading tests and range of motion documentation. 
The enrollee also does not have conservative therapy documented. 
 
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 facet joint injections at C7 and T1 have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the facet joint injections at C7 and T1.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for folic acid, serum (82746) provided November 17, 2021. 
 
You asked the Plan to pay for folic acid, serum. You say that the physician ordered this test which provided the 
clinician with information that has aided in the diagnosis of the enrollee's condition and appropriate treatment 
plan. The Plan denied your request. The Plan says all procedure codes, with the exception of 1 unit of 
procedure code 82746 have been overturned. This service exceeds the maximum number of units allowed for 
this procedure code per day. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
We find that 1 unit of procedure code 82746 was approved for payment. Procedure code 82746 is set as 1 per 
date of service. Based on this information, we decided that Medicare rules for coverage of folic acid, serum 
have not been met. Therefore, we decided that the Plan does not have to pay for folic acid, serum (82746) 
provided November 17, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an adjacent tissue transfer or rearrangement procedure 
(14041) provided on October 18, 2021. 
 
You asked the Plan to pay for an adjacent tissue transfer or rearrangement. You say that the services at issue 
were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have 
not been met because the code at issue is inclusive to another billed code. 
 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 14041 
is a column II code to column I code 14301. 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 an adjacent tissue transfer or rearrangement procedure (14041) 
provided on October 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the compression stockings you purchased on November 1, 
2021 
 You asked the Plan to pay for the compression stockings. You say that you would like coverage of these 
compression stockings because they were not in your over-the-counter catalog. The Plan denied your request. 
The Plan says these items are not covered. 
 
The Plan must follow Medicare rules. The rules say that compression stockings are only covered when used to 
cover a wound.  Compression stockings for the treatment of edema are not covered by Medicare.  
 
Although stockings may be appropriate, they do 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 pay for the compression 
stockings you purchased on November 1, 2021
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a left reverse shoulder replacement procedure. 
 
You asked the Plan to pre-approve the requested reverse shoulder replacement. You say that due to her 
advanced age, the enrollee would have complications from a standard shoulder replacement. It is noted that 
there are studies which show that reverse shoulder replacement is more appropriate for enrollees over the age 
of 70. The Plan denied your request. The Plan says the records do not support the medical necessity of the 
requested procedure. 
 
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 requested reverse shoulder 
replacement. Our reviewer says that the requested services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found this 78-year-old female was being treated for primary 
osteoarthritis left shoulder. She presented with left shoulder pain that is chronic. She localized the pain to the 
mid humerus. She notes the pain has been much worse in the last year and now has a radiation of pain to the 
elbow on occasion. The pain is waking her up most nights. She feels mechanical locking symptoms in the left 
shoulder. Her last injection was about 2 years ago. The exam reveals left shoulder external rotation 40, abduction 65, forward flexion 115. 
 
However, detailed documentation is not evident regarding trial and failure of recent, reasonable, and 
comprehensive less invasive conservative care measures. Additionally, the provided imaging studies do not 
corroborate significant rotator cuff pathology. The peer-reviewed literature recommends this requested 
procedure in the presence of major rotator cuff pathology. There is no compelling rationale presented or 
extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the 
requested left reverse total shoulder arthroplasty, 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 requested reverse shoulder replacement have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a left reverse shoulder replacement procedure.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 36000 billed for date of service November 
20, 2021. 
 
You asked the Plan to pay for procedure code 36000. You say that separate procedures were performed. The 
Plan denied your request. The Plan says no separate payment is made for code 36000. 
 
The Plan must follow Medicare rules. Medicare rules say that for services billed under the Medicare Physician 
Fee Schedule that have a status indicator of B, payment is always bundled into payment for other services.  No 
separate payment is ever made. Procedure code 36000 has a status indicator of B on the Medicare Physician 
Fee Schedule Database. Therefore, we decided that the Plan does not have to pay for procedure code 36000 
billed for date of service November 20, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service December 
16, 2021. 
 You asked the Plan to pay for procedure code 70450. You say that you have submitted medical records to 
support 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 December 16, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic services provided from June 30, 2021, to 
December 7, 2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the denials 
were applied correctly. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by a provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the 
chiropractic services provided from June 30, 2021, to December 7, 2021.