Persius/hicric huggingface dataset:
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer 750MG/15ML solution (CPT code J1439). 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says you do not have any stated contraindications to the preferred products. The Plan 
states you have not tried any of the preferred agents. The Plan states the provider does not provide a rationale 
for use of the non-preferred product for safety or efficacy. 
 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 the medication. Our physician reviewer 
found you have not tried and failed the required drug(s). There is no documentation provided indicating that the 
plans required drug(s) would likely be less effective and/or likely have adverse effects for you. 
 
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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Injectafer 750MG/15ML solution (CPT code J1439).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a reopening of recent laparotomy (49002) provided on 
January 21, 2022. 
 
You asked the Plan to pay for a reopening of recent laparotomy. You say that you have provided records to 
support the service billed. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not allow separate payment for an 
additional procedure(s) with a global surgery fee period if furnished during the postoperative period of a prior 
procedure and if billed without modifier -58, -78, or -79.  
 We looked at the file and Medicare rules. In this case, the record shows that the service at issue was provided 
during the postoperative period of a prior procedure. The service at issue was billed without the appropriate 
modifier. Based on this information, we decided that Medicare rules for coverage of a reopening of recent 
laparotomy have not been met. Therefore, we decided that the Plan does not have to pay for a reopening of 
recent laparotomy (49002) provided on January 21, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the induced abortion, by dilation and curettage (59840) 
provided July 20, 2021. 
 You asked the Plan to pay for the surgical procedure. You say that you are sending medical records to provide 
proof of medical necessity. All codes are covered and should be paid. The Plan denied your request. The Plan 
says this service does not meet coverage requirements. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the surgical procedure have not been met. Therefore, we decided that the Plan does not have to pay 
for the induced abortion, by dilation and curettage (59840) provided July 20, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the muscle and/or fascia debridement (11043), the bone 
debridement (11044), and the bone debridement, each additional 20 square cm (11047) rendered by the out-of-
network (OON) provider on October 5, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of 
network provider, without prior authorization. 
 
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 had network providers available 
who could have provided the services at issue in this appeal. 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 the muscle and/or fascia debridement (11043), the bone debridement (11044), 
and the bone debridement, each additional 20 square cm (11047) rendered by the out-of-network (OON) 
provider on October 5, 2021.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pre-approve a spinal cord stimulator trial. 
 
You asked the Plan to pre-approve a spinal cord stimulator trial. You say that the services are necessary. The 
Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not 
been met. 
 
The Plan follows Medicare rules. Medicare rules say that no payment may be made for the implantation of 
dorsal column or depth brain stimulators or services and supplies related to such implantation, unless specific 
criteria are met. 
 
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 spinal cord stimulator trial. Our 
reviewer says that the services are medically necessary. Our physician reviewer found the enrollee meets all of 
the criteria for a spinal cord stimulator trial. The request is 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 a spinal cord stimulator trial have been met. Therefore, we decided that the Plan 
has to pre-approve a spinal cord stimulator trial.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Evenity. 
 
You asked the Plan to pre-approve Evenity. You say that this is medically necessary. The Plan denied your 
request. The Plan says that you do not have any stated contraindications to the preferred products. 
 
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 Evenity. Our reviewer says that Evenity 
is not medically reasonable and necessary. The Plan requires a trial of Forteo before they will approve the 
requested drug. In this case, you have not tried and failed the required drug. There is no documentation 
provided indicating that the Plan's required drugs would likely be less effective and/or likely have adverse 
effects for you. Our physician reviewer found that your condition does not meet step therapy criteria for 
Evenity. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Evenity have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Evenity.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded as 80307, 83789 and G0480 
provided on January 5, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that the referring physician is a contracted 
provider and has received reimbursement for their services. The drug testing was medically necessary and 
ordered by the enrollee's physician. The Plan denied your request. The Plan says enrollees must receive their 
medical services from an in-network provider with the exception being urgent or emergent services. Non-
emergent services with non-contracted providers require prior authorization before services being rendered. 
 
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 the laboratory services coded as 80307, 83789 and 
G0480 provided on January 5, 2022 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the cardiology visit (CPT code 99203) to be provided by 
an out-of-network provider. 
 
You asked the Plan to pre-approve the out-of-network services. You say that you need a cardiology visit 
because you have congestive heart failure and atrial fibrillation. The Plan denied your request. The Plan says 
there are in-network providers that can provide the services. 
 
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 
the cardiology visit (CPT code 99203) to be provided by an out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa (J7323). 
 
You asked the Plan to pre-approve Euflexxa. You say that the requested drug is medically necessary. The Plan 
denied your request. The Plan says the enrollee has not tried and failed the preferred drugs, Orthovisc or 
Supartz FX. 
 
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 
step therapy criteria have not been met. Our physician reviewer found the provided documentation does not 
indicate that the enrollee has tried and failed the preferred drugs, Orthovisc or Supartz FX. The reviewer found 
that there is no indication that the plan's required drugs would likely be less effective and/or likely have adverse 
effects for the enrollee. Therefore, the reviewer found that the step therapy criteria have not been met. 
 
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 (J7323).
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services provided on November 22, 2021. 
 
You asked the Plan to pay for the anesthesia services. You say that the enrollee was not enrolled in hospice on 
the date of service in this case. The Plan denied your request. The Plan says the enrollees claim would be 
covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of 
election until the last day of the month in which hospice is revoked. The Plan also says it is the providers 
responsibility to verify the enrollees coverage before rendering services and to know proper billing procedures 
for a Medicare Advantage member on hospice. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on November 18, 2021. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the anesthesia 
services provided on November 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99204) rendered by the out-of-network 
(OON) provider on October 13, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization. 
 
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 had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the office visit (99204) rendered by the out-of-network (OON) provider on  
October 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve extraspinal chiropractic treatment (CPT code 98943). 
 
You asked the Plan to pre-approve the service. You say that the chiropractic treatment to extraspinal regions 
(knee) is necessary. The Plan denied your request. The Plan says treatments to line up bones not in the spine 
are not paid by Medicare. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pre-approve extraspinal chiropractic treatment (CPT code 98943).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint interventions (64636). 
 
You asked the Plan to pre-approve facet joint interventions (64636). The Plan denied your request. The Plan 
says facet joint interventions (64636) do not meet the Medicare coverage criteria.  
The Plan follows Medicare 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 pre-approve facet joint interventions (64636). Our 
reviewer says that facet joint interventions (64636) are not medically necessary. Our physician reviewer found 
that the records show that the enrollee has not had the required diagnostic blocks at the L34 level. The review 
has determined that the requested facet joint interventions do not meet the Medicare LCD coverage criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of facet joint interventions (64636) have not been met. Therefore, we decided that 
the Plan does not have to pre-approve facet joint interventions (64636).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Suprep Bowel Solution. 
 
You asked the Plan to pre-approve Suprep Bowel Solution. You say that the records provided support the need 
for the requested Suprep Bowel Solution. The Plan denied your request. The Plan says Suprep Bowel Solution 
is a benefit exclusion as it does not fall under Part B coverage. 
 
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 pre-approve Suprep Bowel Solution.  
 Benefits for Suprep Bowel Solution 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing (G0480) provided on January 11, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for OON drug testing. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says out-of-network care is only covered in certain limited circumstances. The 
provided services were not urgent/emergent, nor were they pre-approved or referred by a contracted 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 drug testing (G0480) 
provided on January 11, 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 interpretation of the abdominal ultrasound provided on 
October 25, 2021, billed with code 76705. 
 You asked the Plan to pay for the ultrasound interpretation. You say that this should be paid as there were 
multiple exams on this date of service. The Plan denied your request. The Plan says this is payable when a 
modifier is used. The provider neglected to report a modifier. 
 
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 76705 
is a column II code to column I code 93976. 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 the interpretation of the abdominal ultrasound provided on 
October 25, 2021, billed with code 76705.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from 
November 19, 2021, through December 18, 2021. 
 You asked the Plan to pay for the SNF services. You say that it is felt that Medicare payment can be made for 
these dates. The Plan denied your request. The Plan says daily skilled services were not required. The claim 
was denied correctly. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the SNF services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found as of 11/18/21, the enrollee did not 
require any skilled nursing or rehab services on a daily basis.  She was not expected to make measurable gains 
within a reasonable and predictable period of time or require skilled therapy to prevent deterioration with 
mobility or daily living activities. The enrollee did not require skilled therapy to establish a safe and effective 
maintenance program. As a practical matter, the enrollee did not require any skilled services on an inpatient 
basis, at a SNF level of care as of 11/18/21. 
 
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 SNF services have not been met. Therefore, we decided that the Plan does 
not have to pay for the skilled nursing facility (SNF) services provided from November 19, 2021, through 
December 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro Motion G orthosis. 
 
You asked the Plan to pre-approve a MyoPro Motion G orthosis. You say that the requested MyoPro Motion G 
is medically necessary. The Plan denied your request. The Plan says the requested MyoPro Motion G 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 a MyoPro Motion G orthosis. Our 
reviewer says that the requested MyoPro Motion G is not medically necessary. Our physician reviewer found at 
this time the requested robotic orthosis is not proven to be more beneficial for treatment of the enrollee's 
medical condition/function of hemiparesis after stroke than any available standard therapy such as conventional 
treatments for post stroke hemiparesis therapy including constraint induced movement therapy, conventional 
muscle strengthening, and botox for spasticity if needed. The requested device is not reasonable and necessary 
for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body 
member. The MyoPro is not known to be effective, based on scientific evidence, professional standards and 
expert opinion, in improving health outcomes in stroke patients. The MyoPro is not in widespread use based on scientific evidence. There is insufficient evidence in the literature that the MyoPro Orthosis will improve the 
long-term outcomes for this enrollee, improve hemiparetic arm function, or be safe for long term use. There is 
insufficient evidence in the literature that this device will increase participation in bimanual activities. 
 
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 MyoPro Motion G orthosis have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a MyoPro Motion G orthosis.