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

 
We decided that the Plan does not have to pre-approve treatment with Brovana (J7605). 
 
You asked the Plan to pre-approve Brovana. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says step therapy rules for the requested drug 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 Brovana. Our reviewer says that the 
requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the 
Plan requires a trial of Perforomist (formoterol) before they will approve the requested drug, Brovana. There is 
no indication that the enrollee 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 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 Brovana have not been met. Therefore, we decided that the Plan does not have 
to pre-approve treatment with Brovana (J7605).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group three power wheelchair with single power 
option and accessories. 
 
You asked the Plan to pre-approve a group three power wheelchair with single power option and accessories. 
You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says 
you do not meet criteria for the requested items. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 While the documentation does show that you have Multiple sclerosis (MS), the documentation does not support 
that you require a group three wheelchair with a power option. The wheelchair evaluation does not demonstrate 
that you are at "High Risk" for development of pressure ulcer. You have a Braden score of 14 which is a 
moderate risk for pressure ulcer. You have no current pressure ulcer or history of pressure ulcer. You do not 
utilize intermittent catheterization for bladder management. The documentation does not support that you need 
either of the power options being requested. This means that Medicare rules for coverage of a power 
wheelchair with power option has not been met. Therefore, we decided that the Plan does not have to pre-
approve a group three power wheelchair with single power option and accessories.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomographic angiography (CTA), abdomen 
and pelvis (74174) provided on January 28, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the CTA. You say that the provider relies on hospital personnel to obtain 
necessary paperwork including authorizations and referrals. The Plan denied your request. The Plan says no 
prior authorization was obtained before the service was rendered to 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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service 
at issue. 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 the computed tomographic angiography (CTA), abdomen and 
pelvis (74174) provided on January 28, 2022 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transcatheter placement of intracoronary stent (92929) 
provided on May 6, 2021. 
 
You asked the Plan to pay for the transcatheter placement of intracoronary stent (92929). You say that the 
documentation supports processing the claim for payment. The Plan denied your request. The Plan says CPT 
codes 92928 and 93454 have been overturned. The Plan also says CPT code 92929 remains denied as bundled 
services are not eligible for separate reimbursement.  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 92929 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 92929 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of the transcatheter placement of intracoronary stent (92929) have not been met. Therefore, we decided that the 
Plan does not have to pay for the transcatheter placement of intracoronary stent (92929) provided on May 6, 
2021.
Appeal type: Drugs
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 you are appealing with supporting records. The Plan 
denied your request. The Plan says the denial of authorization for this drug is correct, because the records do 
not show that the enrollee has received at least 2 intra-articular corticosteroid injections to the knee. 
 
The Plan follows Medicare rules. Medicare rules state that hyaluronan acid therapies for osteoarthritis of the 
knee are only covered if certain criteria are met, including trial of intra-articular corticosteroid injection therapy 
unless it is contraindicated. 
 
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 the Medicare criteria for use of Euflexxa. Our physician reviewer found the records do 
not document trial and failure of intra-articular corticosteroid injection therapy or that this would be 
contraindicated. 
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) 
provided on February 7, 2022. 
 
You asked the Plan to pay for the ambulance service. You say that by the time the ambulance arrived you were 
feeling fine. You say that you were advised you did not need to go to the hospital. You also say that you spoke 
to an ambulance billing specialist who advised this was a billable service and should be covered. The Plan 
denied your request. The Plan says since there was no transport, there is no payable service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on February 7, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no 
transport, (A0998) provided on February 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for telehealth services provided on April 5, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for telehealth services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network and it was 
determined these services were not urgent or emergent. 
 
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. 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 telehealth services provided on April 5, 2022 by 
an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the X-ray exam of the chest (71046-26-59) provided on 
January 17, 2022. 
 
You asked the Plan to pay for the X-ray exam of the chest. You say that you would like this claim reprocessed 
and approved for payment. The Plan denied your request. The Plan says the documentation does not support 
the use of the 59 modifier to bypass the NCCI edit. 
 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 71046 is a column II code to column I code 32555; however, 
71046was billed with a modifier.  
 
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 X-ray exam of the chest. Our reviewer says that the 
documentation does not support payment for CPT code 71046-26-59 as billed. Our reviewer found while a post 
operative chest exam may have taken place, from the attached record there was no information indicating code 
32555 being done by the same provider that would indicate the need for the 59 modifier to be added to 
procedure code 71046. 
 
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 X-ray exam of the chest have not been met. Therefore, we decided that the 
Plan does not have to pay for the X-ray exam of the chest (71046-26-59) provided on January 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for services provided at 24-hour facility, in addition to basic 
service (99053) provided on September 20, 2021. 
 
  You asked the Plan to pay for services provided at 24-hour facility, in addition to basic service (99053). You 
say that the claim denied stating the level of service is not supported but no coding changes are required. You 
say that the medical records should be reviewed, and the claim reconsidered for payment. The Plan denied your 
request. The Plan says procedure codes 99283 and 25630 have been overturn. The Plan also says that procedure 
code 99053 remains denied as bundled services are not eligible for separate reimbursement. 
 
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 99053 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99053 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of services provided at 24-hour facility, in addition to basic service (99053) have not been met. Therefore, we 
decided that the Plan does not have to pay for services provided at 24-hour facility, in addition to basic service 
(99053) provided on September 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the routine ophthalmological examination including 
refraction (S0620) provided on January 4, 2022 by an out-of-network (OON) provider. 
 
  You asked the Plan to pay for the routine examination. You say that you have been going to this provider for 
the past 10 or 12 years. You also say that it is preferred you continue with a location that can follow and treat 
your eye health. The Plan denied your request. The Plan says this service was rendered by a provider who is 
not in the Plan's network. The Plan also says that your benefit plan does not cover this OON vision care 
service/material. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when they are rendered by a Plan approved vision care provider. 
 
We looked at the file and the Plan's rules. The record shows that this service was rendered by an out-of-
network vision care provider. Based on this information, we decided that the Plan's rules for coverage of the 
routine examination have not been met. Therefore, we decided that the Plan does not have to pay for the routine 
ophthalmological examination including refraction (S0620) provided on January 4, 2022 by an out-of-network 
(OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a palatopharyngoplasty. 
 
You asked the Plan to pre-approve a palatopharyngoplasty. You say that this procedure is medically necessary 
for the enrollee's medical condition. The Plan denied your request. The Plan says the requested procedure is not 
an effective treatment for central sleep apnea. 
 
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 palatopharyngoplasty. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee is a 63-year-old man with a diagnosis of obstructive sleep apnea. A 
home sleep test done on November 19, 2021, demonstrated moderate obstructive sleep apnea, with 52 
obstructive apneas, 34 mixed apneas, and 25 central apneas over 586 minutes of recording time.  
The enrollee is obese with an estimated body mass index of 36.46 kg/m2. On 2/1/22 it is documented that with 
his severe depression and claustrophobia, the enrollee does not feel he will be able to tolerate continuous 
positive airway pressure (CPAP) at all. 
 The requested palatopharyngoplasty surgery is rarely indicated as the primary treatment of obstructive sleep 
apnea in adults. For patients who fail or do not tolerate positive airway pressure, treatment options include oral 
appliances and surgical therapy. The documentation does not support that the enrollee in this case is not 
tolerating CPAP therapy with adequate troubleshooting. In addition, the enrollee's body mass index of 36.46 
kg/m2 would be a negative predictor of surgical success. 
 
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 palatopharyngoplasty have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a palatopharyngoplasty.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on November 19, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to appeal the denial of the claim. The 
Plan denied your request. The Plan says The member has no out of network benefits. The servicing provider is 
not a participating provider. 
 
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. 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 office visit provided on November 19, 2021 by 
an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the crown (D2740) provided on January 25, 2022. 
 
You asked the Plan to pay more for the crown. You say that this dental procedure should be covered. The Plan 
denied your request. The Plan says the amount allowed for the crown received was $727.50 and you were 
charged 50% of that amount ($363.75). The Plan also says that this is the appropriate amount for the crown 
received. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, you are responsible for a 50% 
coinsurance for crowns. Therefore, we decided that the Plan does not have to pay more for the crown (D2740) 
provided on January 25, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for Skilled Nursing Facility (SNF) care on 
November 01, 2021, to November 26, 2021.  
 
You asked the Plan to waive the copayment for skilled nursing facility (SNF). You say that you want the plan's 
assistance and help paying the due from you. The Plan denied your request. The Plan says $0 copayment each 
day for days 1-20. $50 copayment each day for days 21-70. $0 copayment for additional Medicare-covered 
days. You pay these amounts until you reach the out-of-pocket maximum.  
 
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 $50 
copayment for days 21-25 of skilled nursing facility care. There were 25 total days, resulting in a total 
copayment amount of $250. The plan did not apply any copayment to the discharge date, November 26, 2021. 
 
 
  
You have been asked to pay a $50 copayment for skilled nursing facility (SNF). Skilled nursing facility (SNF) 
falls within the Skilled Nursing Facility (SNF) care benefit category. You have a $50 copayment for days 21-
25. The provider billed the plan $23,950.12. The allowed amount was $11,000.00 and the plan paid 
$10,750.00. Per your benefits, you are responsible for a $250 copayment. 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 Skilled Nursing Facility (SNF) care on November 01, 2021, to November 26, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided in an outpatient setting 
on October 2, 2021. 
 
You asked the Plan to pay for the self-administered drugs. You say that you do not take any medications. You 
say that you did not receive any self-administered drugs. You also say that you would appreciate any help. The 
Plan denied your request. The Plan says the claim processed correctly. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs 
provided in an outpatient setting on October 2, 2021.  
 
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve shoulder surgery with rotator cuff repair and distal claviculectomy. 
 
You asked the Plan to pre-approve the shoulder surgery. You say that, despite conservative measures which 
included NSAIDs for pain management, the enrollee has not had relief of his pain. You say that the enrollee 
has completed a therapy program and failed conservative treatment. You say that the enrollee continues to have 
severe pain, thus limiting his daily quality of life. The Plan denied your request. The Plan says that the 
guidelines for coverage require a three-month trial of doctor ordered treatment that has not helped. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically 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 the shoulder surgery. Our reviewer says 
that the requested shoulder surgery is considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee was being treated for rotator cuff tear, rupture of the right shoulder. He 
presented with right shoulder pain with weakness, stiffness, and poor range of motion with crepitus (over the 
top of the shoulder in the region of the AC joint) which has been ongoing for over a year. He had a bike 
accident 3 weeks ago, which worsened his pain. The pain is aching and sore and has been progressively 
worsening. He has worsening pain with arm elevation and lying-in bed at night. The pain is rated at 10/10. The 
exam of the right shoulder reveals tenderness of the greater tuberosity and the acromioclavicular joint.  The 
range of motion is flexion 110, abduction 80, external rotation 10 with passive forward flexion at 140, and 
passive abduction at 12. His strength is 5/5. Hawkins, Neers and drop arm testing are positive. There is 
acromioclavicular joint crepitation noted. The provided documentation demonstrates significant subjective and 
objective deficits that are corroborated by imaging studies. Trial and failure of reasonable and comprehensive 
conservative treatment modalities have been documented. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the shoulder surgery have been met. Therefore, we decided that the Plan has to 
pre-approve shoulder surgery with rotator cuff repair and distal claviculectomy.  
 
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.