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

 
We decided that the Plan does not have to pre-approve the L3-pelvis posterior fusion with open SI joint fusion, 
L3 vertebroplasty, and Infuse BMP allograft (22614, 22842, 22632, 22630, 61783, 20936, 20930, 27280, 
22859, 22853) and inpatient admission. 
 
You asked the Plan to pre-approve the L3-pelvis posterior fusion with open SI joint fusion, L3 vertebroplasty, 
Infuse BMP allograft and inpatient admission. You say that this surgery is recommended. The Plan denied your 
request. The Plan says medical studies haven't proven that the application of the product is helpful for treatment 
of your spinal condition when the spinal surgery is being done from a posterior approach. 
 
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 L3-pelvis posterior fusion with open 
SI joint fusion, L3 vertebroplasty, Infuse BMP allograft and inpatient admission. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that there is no nicotine test showing smoking cessation. Smoking is a contraindication to long 
spinal fusion surgery. There must be appropriate evidence of smoking cessation for at least 6 weeks prior to 
surgery. Thus, this procedure and the associated inpatient admission are not covered. 
 
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 L3-pelvis posterior fusion with open SI joint fusion, L3 vertebroplasty, 
Infuse BMP allograft and inpatient admission. have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the L3-pelvis posterior fusion with open SI joint fusion, L3 vertebroplasty, and Infuse 
BMP allograft (22614, 22842, 22632, 22630, 61783, 20936, 20930, 27280, 22859, 22853) and inpatient 
admission.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter. 
 
You asked the Plan to pre-approve a power scooter. You say that you feel you would be able to move around 
your home more easily with a power scooter versus a walker, crutches or cane. You also say that this would be 
more beneficial for your body and healing process from this surgical procedure. The Plan denied your request. 
The Plan says the requested power scooter is not medically necessary. 
 
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.  
 
The file shows that you do not have a mobility deficit that impairs your participation in MRADLs, and your condition can be improved by a walker, cane or manual wheelchair. This means that Medicare rules for 
coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
power scooter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital inpatient or observation care provided on 
August 17, 2023, to August 18, 2023. 
 
You asked the Plan to pay for subsequent hospital inpatient or observation care. You say that the services were 
medically necessary. 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 subsequent hospital 
inpatient or observation care provided on August 17, 2023, to August 18, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair and accessories to be provided by 
an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that this item is medically 
necessary. The Plan denied your request. The Plan says the necessary power wheelchair could be 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 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 
a power wheelchair and accessories to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ultrasound guided injection/aspiration and of biopsy of 
ganglion cyst to be provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve ultrasound guided injection/aspiration and of biopsy of ganglion cyst. You 
say that you need this injection and do not want to visit a doctor that you do not know. The Plan denied your 
request. The Plan says this service is not covered OON. 
 
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 
ultrasound guided injection/aspiration and of biopsy of ganglion cyst to be provided by an out-of-network 
(OON) provider.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Euflexxa (J7323). 
 You asked the Plan to pre-approve Euflexxa. You say that Euflexxa is a medical necessity for the enrollee. The 
Plan denied your request. The Plan says step-therapy rules for coverage of Euflexxa 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 Euflexxa. Our reviewer says that 
treatment with Euflexxa is not medically reasonable and necessary in this case. Our physician reviewer found 
that the Plan requires a trial of Orthovisc or Supartz FX before they will approve the requested drug. In this 
case, the enrollee has not tried and failed the required drugs. There is no documentation provided indicating 
that the Plans required drugs 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 Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve treatment with Euflexxa (J7323).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 76857 performed on March 22, 2023. 
 
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 that the diagnosis code is not specific enough. 
 
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. We find that Diagnosis code N83.209: Unspecified ovarian cyst, unspecified 
side was billed for this claim. The plan did not provide any medical records to substantiate their denial. There is 
no way to determine if this was the most appropriate diagnosis code, or if there was a more specific one that 
was needed. Therefore, we decided that the Plan has to pay for procedure code 76857 performed on March 22, 
2023.  
 
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 the use of Calcipotriene cream. 
 
You asked the Plan to pre-approve the medication. You say that the Calcipotriene is medically necessary for 
the enrollee. The Plan denied your request. The Plan says the medication is not covered as a medical benefit 
under the Plan. 
 
 
 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 the use of Calcipotriene 
cream.  
 
Benefits for the medication 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital inpatient or observation care provided on 
July 26, 2023, to July 27, 2023. 
 
You asked the Plan to pay for subsequent hospital inpatient or observation care. You say that the services were 
medically necessary. 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 subsequent hospital 
inpatient or observation care provided on July 26, 2023, to July 27, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 12001 billed for date of service January 6, 2023. 
 
You asked the Plan to pay for code 12001. You say that this is a payable service. The Plan denied your request. 
The Plan says this service is not separately payable. 
 
The Plan must follow Medicare rules. The rules say that STV-packaged services are services for which separate 
payment is made only if there is no service with status indicator S, T, or V reported on the same claim. If a 
claim includes a service that is assigned status indicator S, T, or V reported on the same claim as the STV- 
packaged service, the payment for the STV-packaged service is packaged into the payment for the service(s) 
with status indicator S, T, V and no separate payment is made for the STV-packaged service. STV-packaged 
services are assigned status indicator Q1. In this case, the code in dispute has a status indicator of QI, meaning 
that it is a STV-packaged service.  This disputed code was billed on the same claim with a code that has a status indicator of S, T, or V.  This means that the code in dispute in this appeal is not separately payable. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 12001 have not been met. Therefore, we decided that the Plan does not have to pay for code 
12001 billed for date of service January 6, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88305 and 88312 billed for date of service 
December 20, 2022. 
 You asked the Plan to pay for procedure code(s) 88305 and 88312. You say that these services were necessary 
and are supported in the medical record. The Plan denied your request. The Plan says these codes are included 
in the facility payment and are not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88305 and 88312. 
This means there is both a professional and technical component for the CPT code(s). In this case, an 
appropriate modifier to indicate the professional component has not been billed with CPT code(s) 88305 and 
88312. Based on this information, we decided that Medicare rules for coverage of procedure code 88305 and 
88312 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code(s) 
88305 and 88312 billed for date of service December 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine panel provided on June 13, 2023. 
 
You asked the Plan to pay for the urine panel. 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. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.  
 
 We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid 
probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for the urine panel provided on June 13, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies.  
 
You asked the Plan to pre-approve incontinence supplies. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the requested items are not covered. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Epicord and Epifix skin substitutes. 
 
You asked the Plan to pre-approve Epicord and Epifix skin substitutes. You say that an open wound has taken 
up residence along with bone being exposed, which is very painful and is needing the bone covered. The Plan 
denied your request. The Plan says the clinical value and effectiveness of Epifix in combination with Epicord 
in the setting of an open wound exhibiting exposed bone with the presence of nonviable tissue and 
osteomyelitis have not been demonstrated in the peer-reviewed literature. 
 
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 Epicord and Epifix skin substitutes. Our 
reviewer says that the requested Epicord and Epifix skin substitutes are not considered medically reasonable 
and necessary. Our physician reviewer found you with a squamous cell cancer on top of your head, which was treated with radiation therapy. The remaining wound is currently described as having osteoradionecrosis, soft 
tissue radionecrosis, and cellulitis with having exposed bone related being treated with antibiotics. A request 
was made for Epicord and Epifix skin substitutes. However, the documentation didn't clearly describe your 
wound as infection-free, and there was evidence of bone exposure which does not meet criteria for skin 
substitute use. There is insufficient high-quality evidence to support this product's use in this clinical setting. 
Therefore, the Epicord and Epifix skin substitutes will be considered not 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 Epicord and Epifix skin substitutes have not been met. Therefore, we decided 
that the Plan does not have to pre-approve Epicord and Epifix skin substitutes.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on June 7, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that this claim was not paid. The Plan denied 
your request. The Plan says this claim was not filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the laboratory services was not filed until July 7, 2023. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for the laboratory services provided on June 7, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient post stabilization provided on March 12, 2023, 
to March 16, 2023. 
 
You asked the Plan to pay for the inpatient post stabilization. You say that the services were medically 
necessary. 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 the inpatient post 
stabilization provided on March 12, 2023, to March 16, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a knee orthosis (L1851) provided on July 17, 2023. 
 
You asked the Plan to pay for the item. You say that this was medically necessary. The Plan denied your 
request. The Plan says a review has determined that the billed services were not supported. 
 
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 item. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there has not been a recent injury or surgery to the knee(s). The most recent exam provided noted a 
Bakers cyst to her right knee that has been hurting her more than normal. This does not indicate a recent injury 
or surgery to the knee(s). Additionally, knee instability has not been documented on exam. The 6/16/23 exam 
reveals pain with lumbar spine tenderness and with lateral rotation. There are no knee objective findings noted. 
Therefore, knee instability has not been documented on exam. 
 
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 item have not been met. Therefore, we decided that the Plan does not have 
to pay for a knee orthosis (L1851) provided on July 17, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the laboratory services provided on July 31, 
2023. 
 
You asked the Plan to waive the copayment for the laboratory services. You say that you disagree with the 
copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 $10 
copayment for in-network outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $10 copayment for the laboratory services. This item/service falls within the in-
network outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for the laboratory services provided on July 31, 2023.