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

 
We decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency 
transport provided on August 31, 2022. 
 
You asked the Plan to pay for the ambulance service, basic life support, non-emergency transport. You say that 
the medical records provided support the need for the ambulance transport. The Plan denied your request. The 
Plan says the ambulance transport was not medically necessary. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 ambulance service, basic life support, 
non-emergency transport. Our reviewer says that the ambulance transport service was not medically necessary. 
Our physician reviewer found the transportation via ambulance from the doctor's office to the enrollee's nursing 
residence was not medically necessary. The enrollee did not require the expertise of trained personnel or the 
equipment available only on an ambulance in order to effectuate a safe transport. Transportation could have 
been provided by other means (stretcher van, wheelchair van, wheelchair van) without endangering the 
enrollee's condition.  
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 ambulance service, basic life support, non-emergency transport have not 
been met. Therefore, we decided that the Plan does not have to pay for the ambulance service, basic life 
support, non-emergency transport provided on August 31, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a left sacroiliac (SI) joint injection (27096).  
You asked the Plan to pre-approve a left sacroiliac (SI) joint injection. You say that the service is medically 
necessary. The Plan denied your request. The Plan says the service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that the diagnostic SIJI must provide a minimum of 75% 
relief of primary (index) pain with the diagnostic SIJI (a positive diagnostic response is defined as greater than 
or equal to 75% sustained and constant pain relief for the duration of the local anesthetic and greater than or 
equal to 75% sustained and constant pain relief for the duration of the anti-inflammatory steroid) was measured 
by the SAME pain scale* at baseline. The measurements of pain must be taken pre-injection on the day of the 
SIJ injection, post-intervention on the day of the injection, and the days following the injection to substantiate 
and corroborate the pain scores consistent with the pain relief for the duration of the local anesthetic and/or 
steroid used. 
 
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 left sacroiliac (SI) joint injection. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found there are no follow-up 
notes detailing the degree and duration of pain relief. 
 
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 left sacroiliac (SI) joint injection have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a left sacroiliac (SI) joint injection (27096).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre Sensor. 
 
You asked the Plan to pre-approve the Freestyle Libre Sensor. You say that you have neuropathy of your 
fingertips and it is especially painful have them pricked. You also say that because of this, the Freestyle Libre 
should be covered. The Plan denied your request. The Plan says you do not require insulin three or more times 
daily. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of the Freestyle 
Libre Sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle 
Libre Sensor.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional mileage for routine transportation (A0170). 
 
You asked the Plan to pre-approve additional mileage for routine transportation. You say that you need to get 
to medical appointments. The Plan denied your request. The Plan says your benefit only allows 100 one-way 
trips with each one-way trip not exceeding 50 miles of driving distance. 
 
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 routine transportation when the driving distance for a one-way trip is within 50 miles.  
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Specifically, the provider is 
located 73 miles away from your residence. The Plan only covers distances up to 50 miles. Therefore, we 
decided that the Plan does not have to pre-approve additional mileage for routine transportation (A0170).
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for the carpal tunnel surgeries received July 8, 2022, and August 5, 2022. 
 
You asked the Plan to pay for the carpal tunnel surgeries. You say that the surgeries should be covered. The 
Plan denied your request. The Plan says that the health plan is not obligated to pay as primary for services 
related to established workers compensation cases. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has not met its obligation with regards to coordination of benefits. Specifically, the record does not 
show that the Plan has sent the bill directly to the primary insurer for payment, directed the provider to send the 
bill to the primary insurer or paid for the services and submitted a bill for reimbursement to the primary insurer. 
Therefore, we decided that the Plan has to pay for the carpal tunnel surgeries received July 8, 2022, and August 
5, 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiological services billed with code 77014 provided on 
November 29, 2022. 
 
You asked the Plan to pay for the radiology services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the 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, the CPT Code Manual definition of code 77014 is computed tomography guidance for placement 
of radiation therapy fields. 
 
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 radiology services provided. Our reviewer says that 
documentation does not support the billed code. Our reviewer found the localization or guidance is integral to 
the interventional procedure and is not separately reportable.  
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 radiology services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for radiological services billed with code 77014 provided on November 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve injection of diagnostic or therapeutic substances (e.g., 
anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle 
or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral (caudal) (62323). 
 
You asked the Plan to pre-approve the injection services. You say that the doctor is requesting an appeal for the 
denial of CPT 62323. The doctor has updated the clinical notes to satisfy the needed documentation per the 
denial. The Plan denied your request. The Plan says the requested services are not reasonable and necessary. 
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the injection services. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee had an Epidural steroid injection and had 100% pain relief for 1-2 days. 
The LCD requires that an Epidural Steroid injection provide at least 50% pain relief for 3 months. This has not 
been achieved here and therefore, the request is deemed 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 injection services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve injection of diagnostic or therapeutic substances (e.g., anesthetic, antispasmodic, 
opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, 
interlaminar epidural or subarachnoid, lumbar or sacral (caudal) (62323).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (11042) provided on July 27, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is not 
supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 11042 is "Debridement, subcutaneous tissue (includes 
epidermis and dermis, if performed); first 20 sq cm or less". 
 
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 services. Our reviewer says that the use of code 11042 is 
not supported by the records provided. Our reviewer found that the medical records provided do not include 
sufficient documentation to validate that "Debridement, subcutaneous tissue (includes epidermis and dermis, if 
performed); first 20 sq cm or less" was performed on July 27, 2022. Therefore, this procedure cannot be 
verified. 
 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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for the services (11042) provided on July 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a stair glide. 
 
You asked the Plan to pre-approve a stair glide. You say that you need this item to get in and out of your house. 
The Plan denied your request. The Plan says this is not covered by Medicare. 
 
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they 
are not primarily medical in nature.  
 
While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pre-approve a stair glide.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99223 billed for date of service July 19, 
2022. 
 
You asked the Plan to pay for the billed services. You say that the billed services are clearly supported. The 
Plan denied your request. The Plan says the billed code cannot be verified. 
 
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 99223 is initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and medical decision making of high complexity.  Counseling and/or coordination of care with other physicians, other qualified health care professionals, or 
agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. 
Usually, the problem(s) requiring admission are of high severity. 
 
We find that CPT code 99223 is not supported in the medical record. The medical records show the enrollee 
presented with complaints of abdominal gassiness/discomfort. The enrollee was in no acute distress and lungs 
were clear. The enrollee denied chest pain, nausea, and fever. The records do not show the presenting problem 
was of high severity. Based on this information, we decided that Medicare rules for coverage of the billed 
services have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 99223 
billed for date of service July 19, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the arthrodesis (22633), laminectomies (63052, 63047, 
63048), posterior non-segmental instrumentation (22840), insertion of interbody biomechanical device (22853), 
autograft (20936), and allograft (20930). 
 
You asked the Plan to pre-approve the arthrodesis, laminectomies, posterior non-segmental instrumentation, 
insertion of interbody biomechanical device, autograft, and allograft. You say that the service is medically 
necessary. The Plan denied your request. The Plan says the service 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 arthrodesis, laminectomies, 
posterior non-segmental instrumentation, insertion of interbody biomechanical device, autograft, and allograft. 
Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found detailed flexion-extension motion films evidencing actual spinal instability 
is unclear and/or not evident. There are limited large-scale, long-term references showing the safety and 
efficacy of the requested surgery in this clinical setting. There is no compelling rationale presented or 
extenuating circumstances noted to support the medical necessity of this request as an exception. 
 
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 arthrodesis, laminectomies, posterior non-segmental instrumentation, 
insertion of interbody biomechanical device, autograft, and allograft have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the arthrodesis (22633), laminectomies (63052, 63047, 63048), 
posterior non-segmental instrumentation (22840), insertion of interbody biomechanical device (22853), 
autograft (20936), and allograft (20930).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of 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 Plan requires a trial of Orthovisc, Supartz FX, Durolane, Monovisc, or Synvisc-One 
before it will approve Euflexxa. 
 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 Euflexxa. Our reviewer says that the 
enrollee does not meet criteria for a step therapy exception for Euflexxa. Our physician reviewer found the 
enrollee has not tried and failed the Plan's preferred drugs of Orthovisc, Supartz FX, Durolane, Monovisc, or 
Synvisc-One. The record does not show that these drugs would likely be less effective and/or 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 Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve use of Euflexxa.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87481 billed for date of service June 9, 2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the 
documentation does not support the billed services. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
In this case, the CPT Code Manual definition of code 87481 is infectious agent detection by nucleic acid (DNA 
or RNA); Candida species, amplified probe technique. 
 
The file shows that 5 units of code 87481 was billed on the date of service at issue. We find that 5 units of CPT 
code 87481 is not supported in the medical record. Specifically, the lab results show that 3 groups of candida 
species were tested. Based on this information, we decided that Medicare rules for coverage of the billed 
services have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 87481 
billed for date of service June 9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller (E2377), expandable controller 
harness (E2313), electronic accessory (E2311), and width extension for footplates (K0108). 
 
You asked the Plan to pre-approve an expandable controller, expandable controller harness, electronic 
accessory, and width extension for footplates. You say that the enrollee is in need of a group 3 power 
wheelchair with power tilt to address their medical and functional needs within the home. The Plan denied your 
request. The Plan says there is not a medical need to control these power options through the joystick. The Plan 
also says code K0108 cannot be approved, as this is incorrectly coded and unbundled. 
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. Medicare rules also say that footplates do have specific codes which are K0040, 
K0041, or K0042. 
 
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 an expandable controller, expandable 
controller harness, electronic accessory, and width extension for footplates. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has adequate upper body strength to manage standard drive switches. Our reviewer 
also found that the foot plates are miscoded as there are specific codes for footplates. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an expandable controller, expandable controller harness, electronic accessory, 
and width extension for footplates have not been met. Therefore, we decided that the Plan does not have to pre-
approve an expandable controller (E2377), expandable controller harness (E2313), electronic accessory 
(E2311), and width extension for footplates (K0108).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair (PWC) with a single power 
option (K0856) and related accessories. 
 
You asked the Plan to pre-approve a group 3 PWC with single power options and related accessories. You say 
that the items are medically necessary. The Plan denied your request. The Plan says the items are not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that the criteria listed in the Medicare Rules section must 
be met for a group 3 PWC and related accessories to be 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 for a group 3 PWC with single power option and 
related accessories. Our reviewer says that these items are not medically necessary. Our physician reviewer 
found that the enrollee does not have any skin breakdown, she does not use a catheter and does not have 
uncontrolled spasticity. 
 
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair Therefore, we decided 
that the Plan does not have to pre-approve a group 3 power wheelchair (PWC) with a single power option 
(K0856) and related accessories.