Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Myopro orthotic device. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says medical studies have not proven that this item is helpful. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the current peer-reviewed medical literature does not support the use of the Myopro orthotic device 
in the setting of traumatic brain injury and brachial plexus injury with rigorous controlled studies showing 
long-term clinical and health benefits. Although records from the device manufacturer/vendor argue medical 
necessity of the requested device, records from the enrollee's actual treating provider do not clarify why the 
requested device is the most appropriate treatment for the enrollee's condition. In addition, provided records 
report a right shoulder subluxation which may be a contraindication to use of the device. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Myopro orthotic device.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa (J7323) and the administration (20610). 
 
You asked the Plan to pre-approve Euflexxa. You say that the requested drug is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee has not tried and failed the preferred drugs, 
Orthovisc, Synvisc, or Synvisc-One. 
 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 records do not indicate that 
the enrollee has tried and failed the plan's preferred step one alternatives. 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 
alternatives. 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) and the administration (20610).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 47361, 47780, 44602, 47801, and 49905 
billed for services provided on September 7, 2021. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the codes 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 47361 is management of liver hemorrhage; exploration of 
hepatic wound, extensive debridement, coagulation and/or suture, with or without packing of liver. The 
definition of code 47780 is anastomosis, Roux-en-Y, of extrahepatic biliary ducts and gastrointestinal tract.  
The definition of code 44602 is suture of small intestine (enterorrhaphy) for perforated ulcer, diverticulum, 
wound, injury or rupture; single perforation. The definition of code 47801 is placement of choledochal stent. 
The definition of code 49905 is omental flap, intra-abdominal (List separately in addition to code for primary 
procedure). 
 We find that CPT codes 47361, 47780, 44602, 47801, and 49905 are not supported in the medical record. The 
medical records do not accurately describe the services as billed. 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 codes 47361, 47780, 44602, 47801, and 49905 billed for services provided on 
September 7, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve facet joint injections (64493 x 2, 64494 x 2). 
 
You asked the Plan to pre-approve the injections. You say that you are in network with the enrollee's plan. You 
also say that these services are medically necessary for the enrollee. The Plan denied your request. The Plan 
says that the services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that Facet Joint Interventions are considered medically 
reasonable and necessary for the diagnosis and treatment of chronic pain in patients who meet all the criteria. 
 
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 medically necessary. Our physician reviewer found the provided documentation 
indicates that the criteria for coverage have been met. Therefore, the reviewer found that the requested 
injections are medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the injections have been met. Additionally, the requested provider is listed as in-
network on the Plan's website. Therefore, we decided that the Plan has to pre-approve facet joint injections 
(64493 x 2, 64494 x 2).  
 
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 pre-approve a repeat transthoracic echocardiography (TTE). 
 
You asked the Plan to pre-approve a repeat TTE. You say that you believe it is imperative for the enrollee to 
proceed with having a repeat echocardiogram. The Plan denied your request. The Plan says the records show 
the enrollee has no new symptoms and is medically stable from a cardiac standpoint. The Plan also says that 
this request is not medically necessary per Medicare rules. 
 
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 repeat TTE. Our reviewer says that a 
repeat TTE is not considered medically reasonable and necessary in this case. Our physician reviewer found the 
documentation would not point to a change in status that would support the medical necessity of a repeat TTE 
at this time. Our reviewer found that the clinical guidelines do not support repeating a TTE following a 
previous TTE, with no intervening change in clinical status or new signs, symptoms or physical findings. Our 
physician reviewer also found that there is no supportive evidence for the medical necessity of repeat TTE in 
this enrollees clinical management. 
 
 
 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 repeat TTE have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a repeat transthoracic echocardiography (TTE).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography, of the heart, without contrast 
material, with quantitative evaluation of coronary calcium (75571). 
 
You asked the Plan to pre-approve this service. You say that this service is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the requested service does not meet Medicare criteria for 
coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
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 this service. Our reviewer says that the 
requested service is not medically necessary. Our physician reviewer found that the enrollee has elevated 
cholesterol but is asymptomatic. Her lifetime cardiac risk score is calculated at 5.1% which is low to 
borderline. The enrollee has not had a stress test or an electrocardiogram. The Center for Medicare and 
Medicaid Services (CMS) does not allow for such screening in asymptomatic patients with a calculated cardiac 
risk score of less than 9%. 
 
We looked at the physicians review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve computed tomography, of the heart, without contrast material, with quantitative evaluation 
of coronary calcium (75571).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Methylpred. 
 
You asked the Plan to pre-approve Methylpred. You say that this medication is not being used for prevention of 
organ transplant rejection. The Plan denied your request. The Plan says the requested drug is considered self-
administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug 
plan. The Plan also says the requested drug is not covered under Medicare Part B. 
 
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 Methylpred.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional power options for a wheelchair (E2300, 
E1012, E2311). 
 
You asked the Plan to pre-approve the items. You say that this is medically necessary. The Plan denied your 
request. The Plan says this 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 items. Our reviewer says that the 
requested items are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the provided records document that the enrollee has 4/5 bilateral upper extremity strength and is 
independent with toileting and eating thus indicating he has adequate upper extremity strength and function to 
operate the wheelchair's power options with their own switches.  
 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 items have not been met. Therefore, we decided that the Plan does not have 
to pre-approve additional power options for a wheelchair (E2300, E1012, E2311).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve right genicular nerve radiofrequency ablation (RFA). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has a history of bilateral 
knee pain due to primary osteoarthritis. Genicular nerve blocks and genicular nerve radiofrequency ablation are 
considered investigational and not medically necessary for the treatment of chronic knee pain. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve right genicular nerve radiofrequency ablation (RFA).  
 The Local Coverage Determination (LCD) referenced by the Plan does not provide coverage criteria for 
genicular nerve RFA and was not used in the MAXIMUS determination.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve behavioral health services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the OON behavioral health services. You say that the requested services are 
medically necessary. The Plan denied your request. The Plan says no medical need has been shown as to why 
the enrollee cannot get the services from a provider within the Plan network. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services with an OON provider. Therefore, we decided that the Plan does not have to 
pre-approve behavioral health services to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 51701 provided on February 17, 2022. 
 
You asked the Plan to pay for code 51701. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the code billed is not separately payable. 
 
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 51701 
is a column II code to column I code 51729 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for code 51701 provided on February 17, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hyalgan. 
 
You asked the Plan to pre-approve Hyalgan. The Plan denied your request. The Plan says the step therapy 
criteria 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 Hyalgan. Our reviewer says that 
Hyalgan is not medically reasonable and necessary in this case. Our physician reviewer found that based on the 
medical records provided, there is no indication that the enrollee has tried and failed the required drug(s). There 
is no indication that the Plan's required drug(s) 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 Hyalgan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Hyalgan.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee from 
March 2, 2022, to March 31, 2022. 
 You asked the Plan to pay for home health services. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the NOA and the claim must 
be completed for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, an 
appropriate NOA claim was not submitted for this period of care. Therefore, we decided that the Plan does not 
have to pay for the home health services provided to the enrollee from March 2, 2022, to March 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (01270, 99100) provided on June 6, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed codes are not 
payable. 
 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 01270 is "Anesthesia for procedures involving arteries of 
upper leg, including bypass graft; not otherwise specified". 
 
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 01270 is 
not supported by the records provided. Our reviewer found that the medical record includes a preoperative 
anesthesia evaluation for a procedure "Creation, bypass, arterial, femoral to popliteal, using graft (Left) - 
reconstruction of left common femoral artery application or replacement, wound vac" for date of service June 
23, 2022. In this case, anesthesia services for date of service June 6, 2022, cannot be verified, as this procedure 
was not included in medical record. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 01270 have not been met. 
 
Additionally, we find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. 
This means that procedure code 99100 is not separately payable. Based on this information, we decided that 
Medicare rules for coverage of code 99100 have not been met. Therefore, we decided that the Plan does not 
have to pay for the services (01270, 99100) provided on June 6, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee requires LTACH care. The 
Plan denied your request. The Plan says the enrollee is receiving appropriate in-patient acute care and does not 
require transfer to an LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the record indicates that the enrollee is improving but still requires acute care 
services before transitioning to a lower level of care. The enrollee continues to receive acute care services, and 
these have not been denied. The medical record does not indicate that the enrollee requires services that are not 
currently being provided, but that would be available at the LTACH facility. The elements of the coverage 
rules 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transthoracic echocardiography (TTE) (93306) provided 
on June 7, 2022.  
You asked the Plan to pay for the TTE. You say that you would like this claim to be reviewed for payment. The 
Plan denied your request. The Plan says this service is not a Medicare benefit for the diagnoses listed on the 
claim and is done for screening. 
 
The Plan follows Medicare rules. Medicare rules say that an echocardiography performed for screening 
purposes 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 TTE. Our physician reviewer found the 
clinical guidelines do not support carrying out a TTE in this setting. Our reviewer also found that there is no 
supportive evidence for the medical necessity of a TTE in this this enrollees clinical management. 
 
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 TTE have not been met. Therefore, we decided that the Plan does not have 
to pay for the transthoracic echocardiography (TTE) (93306) provided on June 7, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for MRA, head; without contrast material(s) (70544) provided 
on February 23, 2022. 
 
You asked the Plan to pay for procedure code 70544. You say that the claim should be paid. The Plan denied 
your request. The Plan says payment for code 70544 is bundled into payment for code 70551. 
 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 70544 
is a column II code to column I code 70551. 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 MRA, head; without contrast material(s) (70544) provided on 
February 23, 2022.