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

 
We decided that the Plan does not have to pre-approve bevacizumab to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve bevacizumab. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is available in-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 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 
bevacizumab to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a core buildup, including any pins when required 
(D2950) and a porcelain/ceramic crown (D2740). 
 
You asked the Plan to pre-approve these dental items. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says insufficient information was received to support the 
items requested in this case. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of these items have been met.  Specifically, the Plan requested additional x-rays and narrative to support the requested dental items in this 
case; however, this information was not provided. Therefore, we decided that the Plan does not have to pre-
approve a core buildup, including any pins when required (D2950) and a porcelain/ceramic crown (D2740).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics (L3020). 
 
You asked the Plan to pre-approve foot orthotics. The Plan denied your request. The Plan says this item is not a 
covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics (L3020).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on December 8, 2022, to 
December 20, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for inpatient hospital services. You say that these services were medically necessary. 
The Plan denied your request. The Plan says these services could have been provided in-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 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 inpatient hospital services provided on December 
8, 2022, to December 20, 2022, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Zolpidem. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this self-administered drug 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 Zolpidem.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (88189) provided on April 6, 2022. 
 You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says this service was not billed with a valid diagnosis code and was performed 
for screening purposes. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, the lab services, was requested solely for screening purposes. Medicare does not 
cover this test solely for screening purposes. Diagnosis code I82.4Z2 is not listed as an approved code for this 
service per Local Coverage Article: Billing and Coding: Flow Cytometry (A57716). Therefore, we decided that 
the Plan does not have to pay for lab services (88189) provided on April 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. The Plan denied your request. The Plan says it is not 
safe to leave the hospital at this time, the enrollee is receiving the care needed in the current hospital. 
 
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 the enrollee is receiving appropriate care at the present acute care hospital and does 
not require services at the LTACH that are not available at the current acute care hospital. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI). 
 
You asked the Plan to pre-approve SSBCI benefits. You say that you feel that the information was filed 
incorrectly. You also say that you have had these benefits in the past. The Plan denied your request. The Plan 
says the criteria for eligibility have not been met. 
 
 
 The Plan must follow Medicare rules. Medicare rules say that, to qualify for SSBCI, an enrollee must have a 
documented chronic condition that is life threatening or significantly limits the health or function of the 
enrollee, has a high risk of hospitalization or adverse health outcomes, and requires intensive care coordination.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI benefits have not been met. Specifically, we have confirmed that you do not have an 
eligible condition that meets all the required criteria. Therefore, we decided that the Plan does not have to pre-
approve special supplemental benefits for the chronically ill (SSBCI).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 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 step therapy criteria are not 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found that the enrollee has age-related 
osteoporosis without current pathological fracture. She has not tried and failed the Plan's required drug, 
zoledronic acid. The records do not show that the required drug would be contraindicated or less effective; 
therefore, Prolia is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Prolia.
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. The Plan denied your request. The Plan says all 
services that would be provided in the LTACH are being provided in the current acute care setting which is 
already approved, when medically stable and no longer requires an acute level of care a lower level of care 
would be appropriate. 
 
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 the enrollee does not require services at the LTACH that are not available at the 
current acute care hospital, all medically necessary care is being provided in the current acute care setting.  
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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit and an electrocardiogram 
provided on November 2, 2022. 
 
You asked the Plan to pay for an emergency department visit and an electrocardiogram. The Plan denied your 
request. The Plan says in order to process this claim we need an Explanation of Benefits from the primary 
insurance carrier. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has not received 
an Explanation of Benefits from the primary insurance carrier. As the secondary insurer, the Plan cannot be 
held responsible for an emergency department visit and an electrocardiogram until the primary insurer has 
denied the claim for these services. Therefore, we decided that the Plan does not have to pay for an emergency 
department visit and an electrocardiogram provided on November 2, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (procedure code 22899) rendered on 
September 15, 2020. 
 
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 documentation does not support this code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 22899 is "Unlisted procedure, spine." 
 
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 22899 is an unlisted code that is 
used to report a procedure that does not have its own CPT code. Based on the documentation, CPT codes exist 
for the procedures performed- a lumbar fusion with cage insertion and instrumentation. An unlisted CPT code 
should not be reported in this case. 
 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 surgical services (procedure code 22899) rendered on September 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99233 provided on March 13, 2022. 
 
You asked the Plan to pay for procedure code 99233. You say that the medical records support the billing of 
code 99233. The Plan denied your request. The Plan says the medical records do not support the billing of code 
99233. 
 
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 99233 is Subsequent hospital care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed 
interval history; A detailed examination; Medical decision making of high complexity. Counseling and/or 
coordination of care with other physicians, other qualified health care professionals, or agencies are provided 
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is 
unstable or has developed a significant complication or a significant new problem. Typically, 35 minutes are spent at the bedside and on the patient's hospital floor or unit. 
 
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 procedure code 99233. Our reviewer says that the medical 
records do not support the billing of code 99233. Our reviewer found the enrollee presented to the emergency 
department on March 13, 2022, with abdominal pain, nausea and vomiting. The evaluation revealed a small 
bowel obstruction (SBO). Current Procedural Terminology (CPT) code 99233 (1 Unit) was not supported. This 
subsequent hospital care evaluation and management code requires two out of these three key components: a 
detailed interval history, a detailed examination and medical decision making of high complexity. In this case, 
the medical records submitted did not support a detailed interval history and medical decision making of high 
complexity. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 99233 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99233 provided on March 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI). 
 
You asked the Plan to pre-approve SSBCI benefits. You say that you do have chronic illnesses that can take 
you to the hospital at any time. The Plan denied your request. The Plan says the criteria for eligibility have not 
been met. 
 
 
 The Plan must follow Medicare rules. Medicare rules say that, to qualify for SSBCI, an enrollee must have a 
documented chronic condition that is life threatening or significantly limits the health or function of the 
enrollee, has a high risk of hospitalization or adverse health outcomes, and requires intensive care coordination.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI benefits have not been met. Specifically, we have confirmed that you do not have an 
eligible condition that meets all the required criteria. Therefore, we decided that the Plan does not have to pre-
approve special supplemental benefits for the chronically ill (SSBCI).
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pay for the Bupivacaine (J3490) provided on March 14, 2022. 
 
You asked the Plan to pay for the Bupivacaine. You say that nothing was paid for this service. The Plan denied 
your request. The Plan says that this is not covered. The Plan also says this service was not authorized by the 
Plan to be rendered by a non-participating provider 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The records do not support that this service is not covered. This means that the 
Plan has not provided a valid reason for denying payment of the Bupivacaine. It is the burden of the Health 
Plan to substantiate their denial with evidence. In this case, the denial has not been substantiated so we must 
find in your favor. Therefore, we decided that the Plan has to pay for the Bupivacaine (J3490) provided on 
March 14, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoperative neurophysiologic monitoring with 
intraoperative electroencephalogram (EEG) rendered on June 7, 2021. 
 
You asked the Plan to pay for the services. You say that this was denied as experimental in error. The Plan 
denied your request. The Plan says this denial was appropriate given applicable guidance. 
 
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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that intraoperative neuromonitoring (IONM) services are not generally supported for use during 
interventional pain management procedures. Such procedures are considered to be extremely "low risk" with 
regards to the central nervous system. No practice guidelines support the use of IONM during such procedures. The enrollee's nervous system was not at risk for injury during the course of this procedure. Nor does current 
literature suggest that the use of IONM during such a procedure otherwise improves the net health outcomes. In 
as much services would not have been 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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for intraoperative neurophysiologic monitoring with intraoperative electroencephalogram (EEG) 
rendered on June 7, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 77080 billed for date of service November 3, 
2022. 
 You asked the Plan to pay for procedure code 77080. You say that the claim was billed correctly and should be 
paid. 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 77080 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 77080 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 77080 billed for date of service November 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (80061) provided on August 01, 2022. 
 
You asked the Plan to pay for laboratory services (80061). You say that the service at issue was a medical 
necessity for the enrollee. The Plan denied your request. The Plan says that unauthorized, out-of-network care 
is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for laboratory services 
(80061) provided on August 01, 2022.