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

 
We decided that the Plan does not have to pre-approve the unlisted molecular pathology procedure (81479). 
 
You asked the Plan to pre-approve the genetic testing. You say that the enrollee had concerns that the 
medication they are taking is not adequately controlling their symptoms. The Plan denied your request. The 
Plan says the records we received did not contain certain details that are needed to process this request. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the genetic testing have been met. Additional records were needed from the provider. The Plan made multiple attempts to obtain the needed 
records without success. Therefore, we decided that the Plan does not have to pre-approve the unlisted 
molecular pathology procedure (81479).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro myoelectric orthotic device (L8702). 
 
You asked the Plan to pre-approve the orthotic device. You say that the enrollee has been referred by their 
family physician for myoelectric restoration. The Plan denied your request. The Plan says this device is 
considered experimental and investigational, and this provider does not participate with Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. The rules also say that experimental and investigational devices are not 
covered. 
 Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pre-approve the MyoPro myoelectric orthotic 
device (L8702).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the continuous glucose monitor (CGM) supplies billed with code 
K0553 for November 26, 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 that there is no valid proof of delivery. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan states that there is no valid proof of delivery in the documentation; 
however, a proof of delivery with all of the required information is present. Therefore, we decided that the Plan 
has to pay for the continuous glucose monitor (CGM) supplies billed with code K0553 for November 26, 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve at home physical therapy to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve at home physical therapy. You say that this should be covered to help the 
patient with daily life tasks. The Plan denied your request. The Plan says 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, the decision is upheld. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
at home physical therapy to be provided by an out-of-network (OON) provider.
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 procedure. You say that this is medically necessary, as there has been 
conservative treatment without relief. The Plan denied your request. The Plan says the case request does not 
meet the standard of care because the physical exam and radiologic studies show additional significant 
pathologies that are unlikely to benefit from the procedure and is not approved. 
 
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 procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the magnetic resonance imaging (MRI) shows multiple degenerative conditions, including 
spinal stenosis.  
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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Intracept procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 10060 billed for date of service June 20, 
2022. 
 
You asked the Plan to pay for procedure code 10060. You say that this was performed on both feet. 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 10060 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 code 10060 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 10060 billed for date of service June 20, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Trivisc. 
 You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the step therapy requirement is not 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found that the enrollee has knee osteoarthritis. 
He has not tried and failed the Plan's required drugs, Durolane, Euflexxa, Supartz FX, and Gelsyn-3. The 
records do not show that the required drugs would be contraindicated or less effective; therefore, Trivisc is not 
reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Trivisc.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional trips for routine transportation beyond the 
Plan's 10-trip limit. 
 
You asked the Plan to pre-approve additional routine transportation. You say that you need transportation to 
follow-up appointments. The Plan denied your request. The Plan says you have exhausted your transportation 
benefit. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 10 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional trips for routine transportation beyond the Plan's 
10-trip limit.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for PET imaging (78816) provided on December 6, 2022. 
 
You asked the Plan to pay for PET imaging. 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 PET scan services must be billed with the 
appropriate diagnosis codes.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of PET imaging have not been met. Therefore, we decided that the Plan does not have to pay for PET 
imaging (78816) provided on December 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (99223, 99233) provided on September 9, 
2022 to September 10, 2022. 
 
You asked the Plan to pay for the physician services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the records do not support the codes 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 codes 99223, & 99233 are initial hospital care requiring a 
comprehensive history, a comprehensive examination and medical decision making of high complexity and 
subsequent hospital care requiring two out of these three key components: a detailed interval history, a detailed 
examination and medical decision making of high complexity. 
 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 the physician services. Our reviewer says that the records do 
not support the billed services. Our reviewer found the medical records submitted do not support a medical 
decision making of high complexity. In addition, the submitted medical records do not include the total time of 
the encounter with more than half of the time spent on counseling and coordination of care. 
 
We looked at this coder's review, the file, and Medicare rules. 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 (99223, 99233) provided on September 9, 2022 to September 10, 
2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 
You asked the Plan to pre-approve Euflexxa. You say that this is medically necessary. The Plan denied your 
request. The Plan says the criteria for coverage have not been met. 
 
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 Euflexxa. Our reviewer says that the 
requested use of Euflexxa is not medically necessary. Our physician reviewer found the record does not 
document that the previous administration of Euflexxa in August 2022 resulted in clinical improvement. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve outpatient manipulation under anesthesia (23700). 
 
You asked the Plan to pre-approve the outpatient procedure. You say that the medical records provided support 
the necessity of the services in dispute. The Plan denied your request. The Plan says the enrollee does not meet 
the medical necessity criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the outpatient procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is being treated for adhesive capsulitis of the left shoulder and presented 
with left shoulder pain that has been ongoing for 6 months. However, detailed documentation is not evident 
regarding a trial and failure of recent, reasonable, comprehensive less invasive conservative care measures including formal physical therapy and/or injection treatment for the left shoulder. There is limited published, 
large-scale, long-term peer-reviewed literature that support the requested surgery over conservative treatments. 
Additionally, there are no diagnostic imaging studies that corroborate pathology and/or rule out other causes of 
pain/findings. There are limited large-scale, long-term references showing the safety and efficacy of the 
requested surgery in this clinical setting. No compelling rationale is presented, or extenuating circumstances 
noted to support the medical necessity of this request as an exception. Therefore, the requested manipulation 
under anesthesia of the shoulder joint (CPT 23700), in this case, is not medically reasonable or necessary.  
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the outpatient procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve outpatient manipulation under anesthesia (23700).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on October 14, 2022, billed with 
procedure codes 74230, 72020, 70100, and 70310. 
 
You asked the Plan to pay for the medical services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the wrong place of service was billed. 
 
The Plan must follow Medicare rules. Medicare rules say that for mobile units serving an entity with its own 
POS code, the entity's POS code should be reported. 
 We looked at the file and Medicare rules. Place of service code 11 was reported however it is not supported. 
The member was at a SNF. Based on this information, we decided that Medicare rules for coverage of the 
medical services have not been met. Therefore, we decided that the Plan does not have to pay for medical 
services provided on October 14, 2022, billed with procedure codes 74230, 72020, 70100, and 70310.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Optimizer Smart Implantable Pulse Generator. 
 
You asked the Plan to pre-approve the Optimizer Smart Implantable Pulse Generator. You say that the 
requested Optimizer Smart Implantable Pulse Generator is medically necessary. The Plan denied your request. 
The Plan says the requested Optimizer Smart Implantable Pulse Generator 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 Optimizer Smart Implantable Pulse 
Generator. Our reviewer says that the requested Optimizer Smart Implantable Pulse Generator is not medically 
necessary. Our physician reviewer found the device is not recommended by any scientific and professional 
body/association as a part of device-based heart failure treatment. 
 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 Optimizer Smart Implantable Pulse Generator have not been met. Therefore, 
we decided that the Plan does not have to pre-approve the Optimizer Smart Implantable Pulse Generator.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for medication assisted treatment, methadone; weekly bundle including 
dispensing and/or administration, substance use counseling, individual and group (code G2067) provided on 
May 16, 2022. 
 
You asked the Plan to pay for medication assisted treatment, methadone; weekly bundle including dispensing 
and/or administration, substance use counseling, individual and group. You say that you have been enrolled in 
the Medicare program to provide Opioid Treatment Program (OTP) services since January 01, 2020. The Plan 
denied your request. The Plan says that this code must be billed by the OTP facility on a facility claim. 
 
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 OTP is the billing provider and is Substance Abuse and Mental 
Health Services Administration (SAMHSA) certified. The rules cited by the Plan do not provide a valid reason 
to deny this claim given that the OTP meets the Medicare coverage criteria. This provider continues to use the 
professional claim, which is allowed under Medicare rules. Therefore, we decided that the Plan has to pay for medication assisted treatment, methadone; weekly bundle including dispensing and/or administration, 
substance use counseling, individual and group (code G2067) provided on May 16, 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 home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that a home ventilator is medically necessary. 
The Plan denied your request. The Plan says the enrollee does not meet criteria for a home ventilator. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our reviewer says 
that the enrollee does not meet criteria for a home ventilator. Our physician reviewer found the enrollee has a diagnosis of chronic obstructive pulmonary disease (COPD), but the medical records do not include pulmonary 
function tests to assess severity. The enrollee was recently hospitalized with pneumonia and COPD 
exacerbation. The enrollee improved on bilevel positive airway pressure (BiPAP).  There is no arterial blood 
gas done while stable showing CO2 retention. If this enrollee has severe COPD and chronic CO2 retention, the 
enrollee may benefit from BiPAP with average volume-assured pressure support (AVAPS) during sleep. 
Medicare does not cover a home ventilator when used at settings that can be provided with BiPAP. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve positron emission tomography (PET) of the brain. 
 
You asked the Plan to pre-approve the PET scan. You say that this is medically necessary. The Plan denied 
your request. The Plan says the medical records provided do not indicate that the enrollee meets the diagnostic 
criteria of both Alzheimer's disease and frontotemporal dementia. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
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 PET scan. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found the service is 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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve positron emission tomography (PET) of the brain.