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

 
We decided that the Plan does not have to pay for the pain management services received from January 10, 
2023, to February 7, 2023. 
 
You asked the Plan to pay for the pain management services. You say that the services should be covered, and 
you submitted your receipts in the time frame required. The Plan denied your request. The Plan says they are 
unable to pay a provider who don't accept any insurance. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the pain management services received 
from January 10, 2023, to February 7, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Practitioner services provided on January 18, 2023, billed 
with procedure code 77012-26-59. 
 You asked the Plan to pay for the Practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says payment for this service is included in the 
payment of another service. 
 
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 77012 is a column II code to column I code 76942; however, 77012 
was billed with a modifier.  
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the Practitioner services provided. Our reviewer says that 
documentation does not support the billed code. Our reviewer found that the report does not include 
documentation to support a distinct procedural service. 
 
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 Practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for Practitioner services provided on January 18, 2023, billed with procedure 
code 77012-26-59.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Trimo-San gel. 
 
You asked the Plan to pre-approve the medication. You say that this is 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 Trimo-San gel.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a computed tomographic angiography (CTA) of the heart 
provided on October 19, 2022. 
 
You asked the Plan to pay for the CTA. You say that the records provided support medical necessity. The Plan 
denied your request. The Plan says the criteria for coverage have not been met. 
 
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 pay for the CTA. Our reviewer says that the service 
was not medically necessary. Our physician reviewer found the documentation provided does not support the 
need for the CTA provided. 
 
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 CTA have not been met. Therefore, we decided that the Plan does not have 
to pay for a computed tomographic angiography (CTA) of the heart provided on October 19, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6530. 
 
You asked the Plan to pre-approve the compression stockings. You say that you have tried regular compression 
stockings, but they do not work for you. The Plan denied your request. The Plan says this compression stocking 
is not covered by Medicare. 
 The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6530.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pre-approve an external electrocardiographic recording (93242). 
 
You asked the Plan to pre-approve an external electrocardiographic recording. You say that it is your 
professional medical opinion that the enrollee should have a thorough evaluation of their clinical abnormalities 
to confirm the abnormalities and intervene immediately. You also say that an outpatient external 
electrocardiogram monitor is part of this evaluation. The Plan denied your request. The Plan says that there is 
no indication that an outpatient external electrocardiogram monitor is medically necessary due to the enrollee 
having no cardiac symptoms such as palpitations or syncope. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an external electrocardiographic 
recording. Our reviewer says that the requested items/services are considered medically reasonable and 
necessary in this case. Our physician reviewer found the enrollee is a 90-year-old with reported palpitations, 
pre-syncope symptoms, with an electrocardiogram showing bradycardia. The enrollee was reported to have a 
high risk for falls. Our reviewer found that this enrollee has clinical symptoms, evidence of bradycardia. Our 
physician reviewer also found that it is appropriate, reasonable, and medically necessary to undergo further 
assessment with the external electrocardiographic recording as requested.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an external electrocardiographic recording have been met. Therefore, we 
decided that the Plan has to pre-approve an external electrocardiographic recording (93242).  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for each infusion therapy provided on 
February 05, 2023, to February 12, 2023. 
 
You asked the Plan to reduce the copayment for each infusion therapy. You say that you should only have a 
$35 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 $260 
copayment for outpatient surgery, including services provided at hospital outpatient facilities. 
 
You have been asked to pay a $260 copayment for each infusion therapy. This item/service falls within the 
outpatient surgery, including services provided at hospital outpatient facilities 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. However, since the allowed amount is 
less than the standard copayment, you only owe $257.76 for each infusion. The total amount you owe is 
$515.52 ($257.76 copayment x 2 visits = $515.52). Therefore, we decided that the Plan does not have to reduce 
the copayment for each infusion therapy provided on February 05, 2023, to February 12, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99285 billed for July 25, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 99285 is not supported by the submitted records. 
 
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 99285 is emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components within the constraints imposed by the 
urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive 
examination; and 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 presenting problem(s) are of high 
severity and pose an immediate significant threat to life or physiologic function.  
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 these services. Our reviewer says that procedure code 99285 
is not supported by the submitted records. Our reviewer found the enrollee was treated in the emergency 
department with sickle cell crisis on July 25, 2022. The documented history included the patient reporting 
generalized pain in torso, legs, back for the past few days with home medications not helping but denies any 
other symptoms. Her vital signs were stable on room air. The examination was unremarkable but detailed. The 
documentation showed a brief, focused history; somewhat detailed exam; but decision-making of low 
complexity. Therefore, code 99285 is not supported. 
 
We looked at this coder'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 pay for procedure code 99285 billed for July 25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Afirma thyroid genomic testing identified with procedure 
code 81546 for date of service November 30, 2022. 
 
You asked the Plan to pay for procedure code 81546. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services provided are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that procedure code 81546 will be rejected as extra-
jurisdictional. 
 
We looked at the file and Medicare rules. Review of the file shows that the code at issue, 81546 is not covered. 
Based on this information, we decided that Medicare rules for coverage of procedure code 81546 have not been 
met. Therefore, we decided that the Plan does not have to pay for the Afirma thyroid genomic testing identified 
with procedure code 81546 for date of service November 30, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vabysmo. 
 You asked the Plan to pre-approve Vabysmo. You say that Vabysmo is medically necessary. The Plan denied 
your request. The Plan says a trial of Lucentis is required before alternatives can be considered. 
 
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 Vabysmo. Our reviewer says that 
Vabysmo is not medically necessary. Our physician reviewer found the records show no trial of the plan 
preferred drug, or any reason it would be unsafe or ineffective. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vabysmo have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Vabysmo.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve inpatient carotid endarterectomy to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve inpatient surgery. You say that the enrollee is scheduled for surgery. The 
Plan denied your request. The Plan says that this provider is out-of-network with the Plan and the enrollee can 
be treated within the Plan network. 
 
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 Plan denied authorization for this service solely because this provider is out-
of-network with the Plan. However, the enrollees contract with the Plan clearly says that the Plan covers out-
of-network inpatient hospital care, including inpatient physician services, using the Plans Point-of-Service 
(POS) option. The enrollee may choose to receive this service from an out-of-network provider, although the 
enrollees cost-sharing may be different for services received under the POS benefit. The Plan did not provide 
any other evidence or rationale to support their denial of authorization for this service. Therefore, the Plan has 
not shown that their decision to deny authorization for this service is correct or justified. Therefore, we decided that the Plan has to pre-approve inpatient carotid endarterectomy to be provided by an out-of-network (OON) 
provider.  
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services billed for date of service August 16, 
2021. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the 
documentation did not support a qualifying inpatient facility stay. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
The file shows that HIPPS code 2H231 was billed, indicating the referral source was institutional. The 
enrollees claim information does not show that the enrollee was in an institution prior to the home health care 
services provided. 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 the home health services billed 
for date of service August 16, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sacroiliac (SI) joint fusion. 
 
You asked the Plan to pre-approve the SI joint fusion. You say that you have tried and failed conservative 
therapies with no long-term relief. You say that you need this procedure to provide more permanent pain relief, 
and less stiffness and weakness. The Plan denied your request. The Plan says this procedure is not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a minimally invasive surgical (MIS) fusion of the 
sacroiliac (SI) joint is considered medically necessary when all of the 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 the SIJ fusion. Our reviewer says that a 
sacroiliac (SI) joint fusion is not medically necessary. Our physician reviewer found there is no documentation 
of pelvis imaging to rule out concomitant hip pathology. Lumbar spine imaging shows multi-factorial causes of 
your low back pain, including scoliosis, retrolisthesis, anterolisthesis, Modic changes, moderate neuroforaminal 
stenosis, and facet arthropathy. There is no documentation of two SI joint injections providing at least 75% 
reduction in pain/ability to perform previously painful maneuvers or a trial of at least one therapeutic intra-
articular SIJ injection. Therefore, the reviewer found that the requested SI joint fusion is not medically 
reasonable or 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 SIJ fusion have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a sacroiliac (SI) joint fusion.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic services provided from February 14, 2023, to 
March 21, 2023. 
 
You asked the Plan to pay for the billed services. You say that the payment seems inconsistent and incorrect. 
The Plan denied your request. The Plan says the services are not payable.  
 
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. Medicare rules say that providers must report 
services correctly. Providers must report services with the appropriate code. 
 The CPT Code Manual definition of code 97012 is application of a modality to 1 or more areas; traction, 
mechanical. This service is not manual manipulation of the spine and not covered when provided by a 
chiropractor. Based on this information, we decided that the Medicare rules for coverage have not been met. 
  
The file shows the claims at issue were billed with diagnosis codes M54.89 and M54.6 We find that diagnosis 
code group M54.8- has an Excludes1 note that includes diagnosis code M54.6. This means the codes should 
not be used at the same time. Based on this information, we decided that the Medicare rules for coverage have 
not been met. Therefore, we decided that the Plan does not have to pay for the chiropractic services provided 
from February 14, 2023, to March 21, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a gel-one injection. 
 You asked the Plan to pre-approve the medication. You say that the medication is medically necessary. The 
Plan denied your request. The Plan says the enrollee has not tried and failed conservative treatment and 
medications. 
 
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 reviewer says that 
the requested medication does not meet the requirements for step therapy guidelines. Our physician reviewer 
found the record indicates that the enrollee has new onset knee pain. Notwithstanding the fact that the 
documents provided are insufficient to establish the diagnosis of osteoarthritis, the requested medication is a 
new start. The record does 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 alternative. 
 
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 a gel-one injection.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (22808, 22845) provided on November 9, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed codes are not 
supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We 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 codes 22808 
and 22845 is not supported by the records provided. Our reviewer found that for code 22808, the 
documentation does not state that an anterior arthrodesis was performed. There is a more specific code for the 
procedure documented. For code 22845, the documentation does not state that anterior instrumentation was 
performed. There is a more specific code for the procedure documented.  
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 the services (22808, 22845) provided on November 9, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital stay provided on April 04, 2023, to 
April 07, 2023. 
 
You asked the Plan to pay for the inpatient hospital stay. You say that these 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 hospital 
stay provided on April 04, 2023, to April 07, 2023.