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

 
We decided that the Plan does not have to pay for surgical services (36903) provided February 17, 2022. 
 
You asked the Plan to pay for the surgical services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says this code is not separately 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. 
 
We find that CPT code 36903 is not supported in the medical record. Specifically, code 36903 is included in 
the global surgery package of code 36558 billed on date of service February 16, 2022. Based on this 
information, we decided that Medicare rules for coverage of the surgical services have not been met. Therefore, 
we decided that the Plan does not have to pay for surgical services (36903) provided February 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (27510, 27752) provided May 5, 2021. 
 
You asked the Plan to pay for the surgical services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the codes billed are not separately 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. 
 
We find that CPT codes 27510 & 27752 are not supported in the medical record. Specifically, code 27510 is 
inclusive to code 27502. Code 27752 is inclusive to code 27532. Based on this information, we decided that 
Medicare rules for coverage of the surgical services have not been met. Therefore, we decided that the Plan 
does not have to pay for surgical services (27510, 27752) provided May 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oxygen equipment (E1390) provided March 10, 2022. 
 
You asked the Plan to pay for the oxygen equipment. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the requested units exceed the allowed amount. 
 
The Plan must follow Medicare rules. Medicare rules say that  rental payments for oxygen equipment is capped 
at 36 months. 
 
We looked at the file and Medicare rules. 36 months of rental payments have already been made for this 
equipment. Based on this information, we decided that Medicare rules for coverage of the oxygen equipment 
have not been met. Therefore, we decided that the Plan does not have to pay for oxygen equipment (E1390) 
provided March 10, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services (99285) provided April 15, 2022. 
 
You asked the Plan to pay for the emergency room services. You say that this service was medically necessary. 
The Plan denied your request. The Plan says this claim cannot be paid 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 find that CPT code 99285 is not supported in the medical record. Specifically, diagnosis codes M54.50 and 
M51.26 cannot be billed together. Based on this information, we decided that Medicare rules for coverage of 
the emergency room services have not been met. Therefore, we decided that the Plan does not have to pay for 
emergency room services (99285) provided April 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics provided by Caputo Foot & Ankle Center on 
March 22, 2022. 
 
You asked the Plan to pay for foot orthotics. The Plan denied your request. The Plan says this item is not a 
covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pay for foot orthotics provided by Caputo Foot 
& Ankle Center on March 22, 2022.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that the records provided support the need for the requested 
drug. The Plan denied your request. The Plan says that the guidelines for coverage have not been met because 
the enrollee does not have hypocalcemia. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 
criteria for coverage have been met. Our physician reviewer found the documentation indicates that the 
enrollee has a diagnosis of osteoporosis. There was no evidence of hypocalcemia at time of administration.  On 
June 24, 2022, serum calcium was 8.6 mg/dL and there was no evidence the hypocalcemia was addressed or 
treated. The review has determined that the requested use of Prolia is FDA-approved for the enrollees 
diagnosis. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
Prolia.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for exercise equipment and online exercise classes. 
 
You asked the Plan to pay for exercise equipment and online exercise classes. You say that you would like to 
be reimbursed for the exercise equipment and classes. The Plan denied your request. The Plan says these 
services are not covered by the Plan. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan benefit does not 
provide coverage for exercise equipment or online classes.  Therefore, we decided that the Plan does not have 
to pay for exercise equipment and online exercise classes.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a trabecular bone score (TBS) provided on 
May 4, 2022. 
 
You asked the Plan to waive the copayment for the TBS. You say that you should not have a copayment for a 
bone density scan. The Plan denied your request. The Plan says you have been charged the correct cost sharing 
amount. 
 
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 $10 
copayment per day for X-rays.  
 
You have been asked to pay a $10 copayment for the TBS. The TBS id an X-ray procedure that is in addition to 
a bone density scan, and falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies 
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 a trabecular bone score (TBS) 
provided on May 4, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for molecular diagnostic testing services provided on January 
11, 2022. 
 You asked the Plan to pay for molecular diagnostic testing. You say that this molecular testing was requested 
directly from the treating physician, who makes the professional determination of diagnosis and medical 
necessity to successfully treat the patient. You say that the enrollee is being treated for abnormal findings in 
specimens from other organs, systems and tissues. The Plan denied your request. The Plan says the claim did 
not include the required DEX Z-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. Medicare rules also say that to report a 
molecular diagnostic test providers must enter the appropriate DEX Z-Code. 
 
We asked our coder 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 molecular diagnostic testing. Our reviewer says that the 
criteria for coverage have not been met. Our reviewer found the service in dispute was report without a DEX Z-
Code.  Beginning October 1, 2021, Medicare requires providers to include the appropriate DEX Z-Code 
identifier on claims. In this case, no DEX Z-Code was reported with service provided, and therefore the service 
was incorrectly reported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of molecular diagnostic testing have not been met. Therefore, we decided that the 
Plan does not have to pay for molecular diagnostic testing services provided on January 11, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 12013 billed for date of service October 23, 
2021. 
 
You asked the Plan to pay for procedure code 12013. You say that this service was medically necessary and 
should be paid. The Plan denied your request. The Plan says this code is not supported in the medical records. 
 
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 12013 is simple repair of superficial wounds of face, 
ears, eyelids, nose, lips and/or mucous membranes.. 
 
 
 We asked our coder 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 procedure code 12013. Our reviewer says that code 12013 is 
not supported in the medical record. Our reviewer found the medical record does not include documentation of 
simple repair of superficial wounds. The patient reported to the emergency department for dialysis catheter 
malfunction, documentation of simple repair of superficial wounds was not found in medical record. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 12013 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 12013 billed for date of service October 23, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from February 
25, 2022, to March 26, 2022. 
 
You asked the Plan to pay for SNF care. You say that it is felt that Medicare payment should be made for these 
services. The Plan denied your request. The Plan says the SNF criteria were not met in this case. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee did not have documented skilled nursing needs. The enrollee did not 
have documented skilled therapy needs. Daily skilled services were not required to establish a maintenance 
program or to prevent deterioration of the enrollees condition. The enrollees care needs were custodial and 
intermittent and could, as a practical matter, be provided at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for skilled nursing facility (SNF) care provided from February 25, 2022, to March 26, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF admission is medically necessary. The Plan 
denied your request. The Plan says Medicare coverage criteria are not met. 
 
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 your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  You were admitted for elective total knee replacement. Medical problems are stable. There are no complex 
nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. 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 you 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve block. 
 
You asked the Plan to pre-approve a genicular nerve block. You say that the clinical documentation provided 
supports that the requested injection is medically necessary. The Plan denied your request. The Plan says the 
requested injection is considered investigational. The Plan says that there are not enough studies showing that 
this injection will improve health care decisions or health outcomes. 
 
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 a genicular nerve block. Our reviewer 
says that a genicular nerve block is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the role of genicular nerve blocks and radiofrequency ablation (RFA) is still being 
determined. At this time, the procedure 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 a genicular nerve block have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a genicular nerve block.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS system. 
 
You asked the Plan to pre-approve a CardioMEMS system. You say that the CardioMEMS implant is 
medically reasonable and necessary. The Plan denied your request. The Plan says there are not enough studies 
to show the CardioMEMS device consistently improves the health of patients with the enrollee's condition. The 
Plan says that the records do not show that the system is being used for care in a Medicare-approved medical 
research study. 
 
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 a CardioMEMS system. Our reviewer 
says that a CardioMEMS system is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there remains a dearth of randomized, blinded clinical studies examining long-term 
clinical outcomes establishing the value of CardioMEMS in patient management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a CardioMEMS system have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMS system.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Granix. 
 
You asked the Plan to pre-approve Granix. You say that this drug is medically necessary for the enrollees 
condition. The Plan denied your request. The Plan says that step therapy criteria have not been met. 
 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 Granix. Our reviewer says that the 
requested drug is not medically reasonable and necessary. Our physician reviewer found that the enrollee is a 
67-year-old female with triple negative breast cancer undergoing chemotherapy. The Plan requires a trial of 
Zarxio before they will approve the requested drug, Granix. There is no indication that the patient has tried and 
failed the required drug. Based on the medical records provided and the Medicare-approved major drug 
compendia there is no indication that the plan's required drug would likely be less effective and/or likely have 
adverse effects for the patient. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Granix have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Granix.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (99291) provided April 9, 2022. 
 
You asked the Plan to pay for the physician services. You say that the service was medically necessary. The 
Plan denied your request. The Plan says the service billed is not separately 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. 
 
We find that CPT code 99291 is not supported in the medical record. Specifically, this service was within the 
global surgery period of procedure 36556. Based on this information, we decided that Medicare rules for 
coverage of the physician services have not been met. Therefore, we decided that the Plan does not have to pay 
for physician services (99291) provided April 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a second opinion consultation to be provided by an out-
of-network (OON) provider. 
 
You asked the Plan to pre-approve the OON second opinion consultation. You say that the enrollee is 
requesting a second opinion for her current treatment of Mantle Cell Lymphoma. You say that the enrollee is 
currently in remission but had a prolonged bout with COVID pneumonia over the course of the last two 
months. You say that the clinical notes provided detail her current clinical status. The Plan denied your request. 
The Plan says the request does not show why the enrollee could not get these services from a facility that is in 
the health plan. The Plan says that this request is medically necessary and will be approved if done in network. 
 
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 enrollee with a second opinion. We found no exception that would require the Plan to pre-approve a second opinion with an OON provider. Therefore, we decided that the Plan does not have 
to pre-approve a second opinion consultation to be provided by an out-of-network (OON) provider.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer. 
 
You asked the Plan to pre-approve Injectafer. The Plan denied your request. The Plan says the enrollee has not 
tried and failed the preferred step therapy drugs Infed and Venofer. 
  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 Injectafer. Our reviewer says that the 
criteria for using Injectafer have not been met. Our physician reviewer found that the enrollee has not tried and 
failed Venofer or Infed. There is no clinical benefit to using Injectafer over Venofer. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Injectafer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Injectafer.