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

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has 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 Prolia. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the provided records do not indicate that 
the enrollee has tried and failed the plan's preferred step one alternative. The record does not indicate that the 
enrollee has a contraindication to, or would have an adverse effect from the plan's preferred step one 
alternative. The elements of the coverage criteria are not satisfied. The requested service cannot be 
recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intravenous infusion, for therapy, prophylaxis, or diagnosis 
(specify substance or drug); initial, up to 1 hour and an esophagogastroduodenoscopy, flexible, transoral; with 
directed placement of percutaneous gastrostomy tube provided on April 22, 2022. 
 
You asked the Plan to pay for intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or 
drug); initial, up to 1 hour and an esophagogastroduodenoscopy, flexible, transoral; with directed placement of 
percutaneous gastrostomy tube. The Plan denied your request. The Plan says the Plan has to pay for care from 
out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they 
approved in advance. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for intravenous infusion, for therapy, prophylaxis, or diagnosis 
(specify substance or drug); initial, up to 1 hour and an esophagogastroduodenoscopy, flexible, transoral; with 
directed placement of percutaneous gastrostomy tube provided on April 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an ultraviolet light therapy system, includes bulbs/lamps, 
timer and eye protection (E0691) provided on April 12, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an ultraviolet light therapy system. You say that you disagree with the denial and 
the medical records support medical necessity. You would like the claim reprocessed and paid. The Plan denied 
your request. The Plan says the requested item is not supported by a referring physician exam. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. The records show there was no referral on file from a referring provider. We found no 
exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does 
not have to pay for an ultraviolet light therapy system, includes bulbs/lamps, timer and eye protection (E0691) 
provided on April 12, 2022, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99254 billed for date of service March 25, 
2022. 
 
You asked the Plan to pay for procedure code 99254. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the billed code is invalid for Medicare 
purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99254 has a Status Indicator of I on the Physician Fee Schedule. This means that procedure code 99254 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 99254 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99254 billed for date of service March 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bilateral Medial Branch Blocks (MBB). 
 
You asked the Plan to pre-approve the MBBs. You say that the pain went down some when you received the 
shot in your back. You say that your legs feel like they have pins and needles in them. You say that physical 
therapy is not going to change what is going on. You also say that you need to be able to walk. The Plan denied 
your request. The Plan says the criteria have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that after the first diagnostic facet joint procedure, there 
must be a consistent positive response of at least 80% relief of primary (index) pain. 
 
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 MBBs. Our reviewer says that the 
requested Medial Branch Blocks (MBBs) are not medically necessary. Our physician reviewer found there is 
no documentation provided indicating that the previous MBB provided a consistent positive response of at least 
80% relief of primary (index) pain (with the duration of relief being consistent with the agent used). Therefore, 
the reviewer found that the requested MBBs are 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 MBBs have not been met. Therefore, we decided that the Plan does not have 
to pre-approve bilateral Medial Branch Blocks (MBB).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dialysis services (G0491, 90999) to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve dialysis services. You say that there was mistreatment of care for the 
enrollee in the contracted facility. You also say that you would like the enrollee transferred back to the Atlantis 
facility. The Plan denied your request. The Plan says Atlantis is a non-contracted provider starting 6/1/2022. In 
March 2022, the Plan notified the enrollee in writing, the cancellation of the Atlantis Healthcare Dialysis 
Center. The notification explained that the Plan will transition enrollees dialysis services with a contracted 
dialysis center, Fresenius Kidney Care, to assure the quality and continuity of care for the enrollee. 
 
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 
dialysis services (G0491, 90999) to be provided by an out-of-network (OON) provider.  
 
Maximus read your letter and knows that you may have a quality of care concern. Maximus cannot address 
quality of care issues. We are forwarding your quality of care concern to the appropriate Quality Improvement 
Organization for further review.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nurse practitioner services provided from July 20, 2021, to 
November 4, 2021. 
 
You asked the Plan to pay for nurse practitioner services. The Plan denied your request. The Plan says in most 
cases, care that the enrollee receives from an out-of-network provider will not be covered. The only exceptions 
would be emergency care, urgently needed services and renal dialysis out of the area. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for nurse practitioner services provided from July 20, 2021, to 
November 4, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for external electrocardiographic recording (procedure codes 
93246, 93248) provided to the enrollee on March 23, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the units exceed the days in the time span. 
 
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 the denied codes is: 
 
CPT 93246: 
 
External electrocardiographic recording for more than 7 days up to 15 days by continuous rhythm recording 
and storage; recording (includes connection and initial recording) 
 
CPT 93248: 
 External electrocardiographic recording for more than 7 days up to 15 days by continuous rhythm recording 
and storage; review and interpretation 
 
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 services at issue in 
this case were not supported by the medical records. Our reviewer found that remote interrogation services 
93248 and 93246 are 15-day services and may only be reported once during the 15-day period. A clinic note 
documents an Exam time of 4:23 PM on 3/9/2022 for an Event Recorder. A cardiology note with an Encounter 
Date of 3/9/2022 documents that the enrollee "was patched with a Zio Monitor on 03/23/2022, by patient." The 
billed date of service of 3/23/2022 is included in the coverage period of 15 days. 
 
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 external electrocardiographic recording (procedure codes 93246, 93248) provided to the 
enrollee on March 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic care provided on May 10, 2022. 
 
You asked the Plan to pay for chiropractic care. The Plan denied your request. The Plan says that the Plan has 
paid the maximum amount covered by the Plan. 
 
The Plan contract covers additional services received from a licensed chiropractor. The Plan covers 30 visits 
each calendar year with a licensed chiropractor for additional services. 
 
We looked at the file and the Plans rules. The file shows that the Plan has paid the maximum benefit amount. 
Therefore, we decided that the Plan does not have to pay for chiropractic care provided on May 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95910 billed for date of service September 
16, 2021. 
 You asked the Plan to pay for procedure code 95910. You say that you have provided medical records to 
support the services billed. 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 95910 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 95910 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 95910 billed for date of service September 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroiliac (SI) joint injections with imaging guidance 
(27096). 
 
You asked the Plan to pre-approve the injections. You say that the enrollee has had 2 SI joint injections 
previously. You say that neither were done with imaging guidance. You say that both had inconsistent results. 
You also say that the image guided injection is necessary so the results can be verified. The Plan denied your 
request. The Plan says the requested injections are 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 injections. Our reviewer says that 
the requested injections are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the clinical value and effectiveness of a sacroiliac (SI) joint injection in the absence of 
tenderness and negative provocative testing results have not been demonstrated in the peer-reviewed literature. 
The reviewer found there is no documentation provided that supports the enrollee's history of SI joint pain. 
There is no documentation on physical examination of tenderness to the SI joint and no mention of SI 
provocative testing being completed with positive findings. Therefore, the reviewer found that the requested sacroiliac joint injection 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 injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve sacroiliac (SI) joint injections with imaging guidance (27096).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for injections on April 08, 2022. 
 
You asked the Plan to waive the coinsurance for injections. You say that you want to appeal the amount being 
charged. The Plan denied your request. The Plan says the cost sharing you are being charged is correct. 
 
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 20% 
coinsurance for Part B prescription drugs. These drugs are covered under Part B of original Medicare. 
Members of our plan receive coverage for these drugs through our plan. Covered drugs include drugs that 
usually arent self-administered by the patient and are injected while you are getting physician, hospital 
outpatient, or ambulatory surgical center services. The provider billed in the amount of $22,200 and the 
allowed amount $4,982. The Plan paid $4,982. $4,982 - $4,183 = $799.00. Therefore, results in the total cost 
sharing amount of $799. 
 
 
 
 You have been asked to pay a 20% coinsurance for injections. Injections fall within the Medicare Part B 
prescription drugs 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 coinsurance for injections on April 
08, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment (E0105) provided on June 24, 
2021. 
 
You asked the Plan to pay for the durable medical equipment. 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 state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid physician order or proof of delivery 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 the durable medical equipment (E0105) provided 
on June 24, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71045 billed for date of service April 29, 
2022. 
 
You asked the Plan to pay for procedure code 71045. You say that the enrollee had multiple exams. The Plan 
denied your request. The Plan says payment for code 71045 is bundled into payment for code 32557. 
 
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 71045 
is a column II code to column I code 32557. 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 71045 billed for date of service April 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on April 6, 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 procedure code 81455 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 81455 is targeted genomic sequence analysis panel, solid 
organ or hematolymphoid neoplasm, DNA analysis, and RNA analysis when performed, 51 or greater genes 
(eg, ALK, BRAF, CDKN2A, CEBPA, DNMT3A, EGFR, ERBB2, EZH2, FLT3, IDH1, IDH2, JAK2, KIT, 
KRAS, MLL, NPM1, NRAS, MET, NOTCH1, PDGFRA, PDGFRB, PGR, PIK3CA, PTEN, RET), 
interrogation for sequence variants and copy number variants or rearrangements, if performed. 
 
We find that CPT code 81455 is not supported in the medical record. Specifically, the specimen was not 
collected on the billed date of service. 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 pay for the laboratory 
services rendered on April 6, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous implantation of neurostimulator electrode 
array, epidural (63650). 
 
You asked the Plan to pre-approve these services. You say that you need this approved because you are in pain. 
The Plan denied your request. The Plan says that your records show you have not been evaluated by a 
psychologist. 
 
The Plan must follow Medicare rules. Medicare rules say that patients must have undergone careful screening, 
evaluation and diagnosis by a multidisciplinary team, including a psychological evaluation, prior to 
implantation of a spinal cord stimulator. 
 
We looked at the file and Medicare rules. There is no psychological evaluation in the case file. 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 percutaneous implantation of neurostimulator electrode 
array, epidural (63650).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76140 billed for date of service February 24, 
2022. 
 
You asked the Plan to pay for procedure code 76140. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the billed code is invalid for Medicare 
purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. We find that procedure code 76140 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 76140 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 76140 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 76140 billed for date of service February 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care rendered on January 8, 2022, to 
January 9, 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 the services are not separately payable. 
 
The Plan must follow Medicare rules. The rules say that post-surgical management and post-operative care are 
included in the global surgical package. 
 
 
 
 
 
 
 
 
 
 
 We looked at the file and Medicare rules. The file shows that the subsequent hospital care was billed within the 
global surgical period for major procedures 27091 and 27252 on December 2, 2021 and December 11, 2021. 
Payment for the hospital care is included in the global surgical package. Therefore, we decided that the Plan 
does not have to pay for the subsequent hospital care rendered on January 8, 2022, to January 9, 2022.