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

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 You asked the Plan to pre-approve Euflexxa. The Plan denied your request. The Plan says the enrollee has not 
tried one of the preferred drugs.  
 
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 physician reviewer found 
that the enrollee has a diagnosis of unilateral primary osteoarthritis of the left knee. The Plan requires a trial of 
Monovisc, Orthovisc, Synvisc, or Synvisc One before they will approve the requested drug. The case file does 
not contain documentation of trial and failure of the required drugs. The documentation does not support that 
the Plans required drugs would likely be less effective, and/or would likely have adverse effects for the 
enrollee in this case.  
 
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.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Doxepin capsules. 
 
You asked the Plan to pre-approve Doxepin capsules. 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 Doxepin capsules.   
Benefits for Doxepin capsules 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: 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 services are medically necessary to 
get the enrollee strong enough to return home at baseline. The Plan denied your request. The Plan says the 
enrollee is receiving appropriate inpatient acute care and is currently unstable for 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 there is no evidence that the enrollee requires services that are not currently available. 
The enrollee can remain at the current acute care hospital until such time no acute services are required. The 
enrollee can then be transferred or discharged to a lower level of care for any ongoing LTC needs. 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 38570-59 and 58571 billed for date of 
service October 3, 2022.  
 
You asked the Plan to pay for procedure codes 38570-59 and 58571. You say that code 38570 should not be 
bundled because the doctor performed a resection of the lymph nodes in addition. You also claim that you 
originally billed code 58548, but you have submitted a corrected claim. The Plan denied your request. The Plan 
says payment for codes 38570-59 and 58571 is bundled into payment for code 58548. 
 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 codes 
38570-59 and 58571 are column two codes to column one code 58548 with a modifier indicator of 0. The 
column two codes are 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 procedure codes 38570-59 and 58571 
billed for date of service October 3, 2022.   
 
Please note that you indicated that you submitted a corrected claim to the Plan.  Our decision is based on the 
original claim submitted.  Any questions regarding a corrected claim need to be sent to the Plan directly.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hip orthosis (L1686), provided on May 30, 2023. 
 
You asked the Plan to pay for the hip orthosis. You say that the item was medically necessary. The Plan denied 
your request. The Plan says the documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. There is no indication this item was needed or ordered in the clinical documentation submitted. The record shows that the Plan made several attempts to obtain the necessary documentation without success. 
Therefore, we decided that the Plan does not have to pay for the hip orthosis (L1686), provided on May 30, 
2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (E0676) for date of 
service April 21, 2023. 
 
You asked the Plan to pay for the pneumatic compression device. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says payment is not allowed for this service because it is not 
billed with valid Current Procedural Terminology (CPT)-4 code. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service.  
  
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for the pneumatic compression device (E0676) for date of service April 21, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hyaluronan or derivative, Monovisc, for intra-articular 
injection, per dose (J7327).  
 You asked the Plan to pre-approve the medication. You say that please reconsider the denial. The Plan denied 
your request. The Plan says the enrollee has not trialed or presented with an inadequate response or intolerance 
to two preferred hyaluronan agents. 
 
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 items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found step therapy, as outlined by the Plan, requires that one of the preferred viscosupplemental 
treatments (Euflexxa, Supartz FX, Durolane, or Gelsyn-3) be trialed first. The documentation does not outline 
contraindications or reasons these medications were not considered or that the Plan's additional required drugs 
would likely be less effective and/or likely have adverse effects for the enrollee. Without the support of the 
documentation, Monovisc is not approved as step 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 the medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Hyaluronan or derivative, Monovisc, for intra-articular injection, per dose (J7327).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc (J7325). 
 You asked the Plan to pre-approve Synvisc. The Plan denied your request. The Plan says this request does not 
meet the Plan's Part B step therapy criteria for the requested viscosupplement device. 
 
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 Synvisc. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found 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 drug(s). Our physician reviewer also found that there is no documentation provided indicating 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 Synvisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Synvisc (J7325).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee orthosis (L1851) and suspension sleeve (L2397) 
provided May 30, 2023.  
 
You asked the Plan to pay for the orthoses. You say that please see attached medical records. The Plan denied 
your request. The Plan says the orthosis and accessory are not medical necessity. 
 
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 orthoses. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee was recently seen by their physician. No knee complaint was documented. A knee 
orthosis (L1851) and suspension sleeve (L2397) were provided May 30, 2023. However, the provided 
documentation states the enrollees primary physician stated that they did not order them and that the enrollee 
did not need them. There was no other objective examination findings or history that would support a condition 
where this knee brace would be warranted. Therefore, this request for knee orthosis 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 the orthoses have not been met. Therefore, we decided that the Plan does not 
have to pay for the knee orthosis (L1851) and suspension sleeve (L2397) provided May 30, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99222 billed for date of service June 20, 
2023.  
 
You asked the Plan to pay for procedure code 99222. You say that the services at issue were a medical 
necessity for the enrollee. 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 submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 99222 is 1. The MAI value for this code is 3. You billed 2 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 99222 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 99222 billed for date of service June 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the VIA Disc NP procedure. 
 
You asked the Plan to pre-approve the procedure. You say that this procedure is necessary due to the failure of 
conservative treatments to address pain and restore function. The Plan denied your request. The Plan says 
experimental and investigational procedures are not covered. 
 
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 procedure. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the provider is requesting the injection of VIA Disc into the spinal disc for advanced 
degenerative disc disease against FDA approval guidelines. Large well-designed studies in the peer review 
scientific literature comparing stand-alone use of VIA Disc to established treatments are needed.  Published 
studies do not demonstrate any long-term health outcome advantage with the use of VIA Disc NP as an 
alternative to standard treatments. 
 
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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the VIA Disc NP procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional moderate sedation time provided on date of 
service May 24, 2023, billed with code 99153. 
 
You asked the Plan to pay for procedure code 99153. You say that the claim is billed correctly and should be 
paid. The Plan denied your request. The Plan says code 99153 is not payable in the facility setting.  
 
Medicare rules say that the OPPS recognizes that CPT code 99153 is a PE only code and that PE are not 
payable to the physician for services provided in the facility setting.   
We find that payment for CPT code 99153 is not supported. Specifically, there is no separate payment to the 
physician for CPT code 99153 when performed in the facility setting. Therefore, we decided that the Plan does 
not have to pay for the additional moderate sedation time provided on date of service May 24, 2023, billed with 
code 99153.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99233 billed for date of service May 5, 2023. 
 
You asked the Plan to pay for code 99233. You say that this code is supported by the medical records. The Plan 
denied your request. The Plan says code 99233 is not supported by the medical record. The medical records 
submitted don't support high level of medical decision making or total time required of the code billed. 
 
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 inpatient or observation 
care, per day, for the evaluation and management of a patient, which requires a medically appropriate history 
and/or examination and high level of medical decision making. When using total time on the date of the 
encounter for code selection, 50 minutes must be met or exceeded. 
 
 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 code 99233. Our reviewer says that code 99233 is not 
supported by the medical record. Our reviewer found the patient is a 76-year-old female who was treated for 
weakness. The documentation from this date describes the patient as without new complaints, stable vitals, no 
fractures or other acute findings on imaging, and a normal examination. Hyponatremia was diagnosed and was 
being treated with sodium and fluids. Physical therapy was continued. The history and examination were 
appropriate; however, the documentation did not sufficiently support a high level of medical decision-making 
or a duration of the encounter being 50+ minutes to help justify the code, 99233.  
 
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 99233 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99233 billed for date of service May 5, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lumbar-sacral orthosis provided on June 14, 2023. 
 
You asked the Plan to pay for the orthosis. The Plan denied your request. The Plan says the documentation 
requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain relevant medical records which support medical necessity for the orthosis provided 
in this case. The records provided do not mention that the enrollee had pain or a condition which required the requested orthosis. The enrollee indicated that she told the provider that she did not need a brace and requested 
that one was not sent to her. The record shows that the Plan made attempts to obtain the necessary 
documentation without success. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral 
orthosis provided on June 14, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an abdominoplasty. 
 
You asked the Plan to pre-approve an abdominoplasty. You say that an abdominoplasty is medically necessary. 
The Plan denied your request. The Plan says the requested abdominoplasty is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that an abdominoplasty is covered when the criteria listed 
in the Medicare rules section of this decision 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 an abdominoplasty. Our reviewer says 
that the requested abdominoplasty is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that in this case, the record indicates that the enrollee has a pannus following weight 
loss. The record provided does not document that the pannus extends below the pubis, the presence of 
functional impairment, or the presence of intertrigo refractory to conservative treatment. The elements of the 
coverage criteria are not satisfied. 
 
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 abdominoplasty have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an abdominoplasty.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 2 standard power wheelchair (K0823) and two 
U-1 sealed lead acid batteries (E2365 x2). 
 
You asked the Plan to pre-approve a group 2 standard power wheelchair and two U-1 sealed lead acid batteries. 
The Plan denied your request. The Plan says the request for a power wheelchair is denied as 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.  
 
 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 group 2 standard power wheelchair 
and two U-1 sealed lead acid batteries. Our reviewer says that the group 2 power wheelchair and accessories 
are not medically necessary. Our physician reviewer found the patient appears to be functionally non-
ambulatory, but the documentation does not specify the patients level of mobility and if they are currently 
using an assistive device for mobility and how far they can ambulate. The patient is noted to have 3 out of 5 
motor strength in the upper extremities. Our reviewer found while it is stated that the patient cannot propel a 
manual wheelchair, the clinical documentation does not support this. Additionally, the patient requires set up 
assistance with daily activities and contact guard assistance with transfers and this does not support that the 
patient is unable to perform pressure relief independently. Our physician reviewer also found that there is a 
lack of documentation indicating that the patient cannot use a manual wheelchair for mobility, if they are at risk 
for falling, and cannot perform their daily activities. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a group 2 standard power wheelchair and two U-1 sealed lead acid batteries 
have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 2 standard power 
wheelchair (K0823) and two U-1 sealed lead acid batteries (E2365 x2).