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

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 
You asked the Plan to pre-approve Euflexxa. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Euflexxa. Our reviewer says that the 
documentation does not support that the requested drug is medically reasonable or necessary. Our physician 
reviewer found the enrollee has a diagnosis of osteoarthritis of the knee. The record provided insufficiently 
documents the failure of conservative nonpharmacologic therapy. The Food and Drug Administration has not 
stated that the requested drug is indicated for the enrollee's condition. The Medicare approved drug compendia 
do not contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. 
Therefore, the enrollee does not meet criteria for the requested drug. 
 
 
 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the stab phlebectomy (37766, 37765). 
 
You asked the Plan to pre-approve the stab phlebectomy. You say that the service is medically necessary. The 
Plan denied your request. The Plan says the service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that Phlebectomy will be considered medically reasonable 
and necessary for symptomatic bulbous varicosities greater than 3mm diameter above and below the knees.  
 
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 stab phlebectomy. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found there is no documentation that 
patient is having any significant complaint in the left leg. Criteria require that for a procedure to be considered 
medically necessary there must be symptoms attributable to the veins in question that are severe enough to 
interfere with activities of daily living or quality of life.  As there has been no documentation of significant 
symptoms in the left leg, coverage criteria not 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 stab phlebectomy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the stab phlebectomy (37766, 37765).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the screening mammogram provided on January 18, 2023. 
 
You asked the Plan to pay for the screening mammogram. You say that you are requesting reconsideration for 
the denied payment. 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 screening 
mammogram provided on January 18, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of a ventilator. 
 
You asked the Plan to pre-approve ventilator. You say that the enrollee needs a ventilator machine. The Plan 
denied your request. The Plan says a ventilator is not covered by Medicare for this purpose and the needed 
therapy can be delivered by a bilevel positive airway pressure (BiPAP) device. 
 
The Plan must follow Medicare rules. Medicare rules say that ventilator products used to provide positive 
airway pressure (PAP) therapy, regardless of the underlying medical condition, shall not be covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve use 
of a ventilator.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the laboratory services provided on January 
12, 2023. 
 
You asked the Plan to waive the deductible for the lab services. You say that this service should be covered 
under preventative care. 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. Your 
contract with the Plan says that there is a $300 deductible which applies to outpatient diagnostic tests and 
therapeutic services and supplies.  
 
 
 
 You have been asked to pay $86.12 towards your deductible for the lab services. The item or service you asked 
the Plan to waive the deductible for falls within the outpatient diagnostic tests and therapeutic services and 
supplies benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there 
is a $300 deductible which applies to outpatient diagnostic tests and therapeutic services and supplies. This cost 
sharing is a contractual obligation that had not been met at the time the lab services was received on January 
12, 2023. Therefore, we decided that the Plan does not have to waive the deductible for the laboratory services 
provided on January 12, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pain management, analysis of 11 endogenous analytes, 
(Foundation Pain Index) (0117U) provided November 2, 2022. 
 
You asked the Plan to pay for the Foundation Pain Index. You say that you are appealing this decision and 
would like reconsideration of coverage of this procedure. The Plan denied your request. The Plan says this 
service is not covered by Medicare. 
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Foundation Pain Index have not been met. Therefore, we decided that the Plan does not have to 
pay for pain management, analysis of 11 endogenous analytes, (Foundation Pain Index) (0117U) provided 
November 2, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve mitral valve replacement, with cardiopulmonary bypass 
(33430) and associated inpatient hospital stay. 
 
You asked the Plan to pre-approve mitral valve replacement, with cardiopulmonary bypass and associated 
inpatient hospital stay. You say that this is medically necessary. The Plan denied your request. The Plan says 
the requested service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
   
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve mitral valve replacement, with 
cardiopulmonary bypass and associated inpatient hospital stay. Our reviewer says that the requested 
items/services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found echocardiography in June 2023, assessed the mitral regurgitation as less than severe. As such, the 
documentation would not suggest that the mitral regurgitation is of sufficient severity to warrant valve 
replacement. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of mitral valve replacement, with cardiopulmonary bypass and associated inpatient 
hospital stay have not been met. Therefore, we decided that the Plan does not have to pre-approve mitral valve 
replacement, with cardiopulmonary bypass (33430) and associated inpatient hospital stay.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the OTC items provided on January 30, 2023. 
 
You asked the Plan to pay for the OTC items. You say that you were unable to use your OTC credit because 
the system was down, and you submitted for reimbursement.  The Plan denied your request. The Plan says the 
service is not a covered benefit. Specifically, the service was provider was not in-network. 
 
Medicare generally does not cover OTC services. However, the Plan offers an OTC benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The record shows you received the requested OTC items from an out-of-network provider. Though the Plan 
offers an OTC benefit in excess of Medicare coverage, the requested items are not covered under this benefit 
when received from an out-of-network provider. Therefore, we decided that the Plan does not have to pay for 
the over-the-counter (OTC) items provided on January 30, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implantation of the Minuteman G3R interspinous device 
to L4-L5 (22612, 20930, 22840). 
 
You asked the Plan to pre-approve implantation of the Minuteman G3R interspinous device to L4-L5. You say 
that this is medically necessary. The Plan denied your request. The Plan says the clinical value and 
effectiveness of the Minuteman interspinous device in the setting of lumbar radiculopathy has 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 implantation of the Minuteman G3R 
interspinous device to L4-L5. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found the Minuteman device is experimental. 
More research is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of implantation of the Minuteman G3R interspinous device to L4-L5 have not 
been met. Therefore, we decided that the Plan does not have to pre-approve implantation of the Minuteman 
G3R interspinous device to L4-L5 (22612, 20930, 22840).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided from July 19, 2022, to 
July 23, 2022, at the DRG originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
claim should be reconsidered for additional payment. The Plan denied your request. The Plan says diagnosis 
code E43 is not supported, which resulted in a DRG change. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services with diagnosis code E43, defined as unspecified severe protein-
calorie malnutrition. 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 inpatient hospital 
services at the DRG originally billed. Our reviewer says that the diagnosis is not supported. Our physician 
reviewer found there was no detailed report of at least 50% reduction in calorie requirements or weight loss of 
more than 10% in the past 6 months. Therefore, the records do not match the diagnosis of severe protein-
calorie malnutrition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided from July 19, 2022, to July 23, 2022, at the DRG originally billed.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for the home health care billed for dates of service July 21, 2021, to 
August 17, 2021. 
 
You asked the Plan to pay for the billed services. You say that medical records were provided. The Plan denied 
your request. The Plan says that physician orders were not signed. 
 
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. 
 
We looked at the file and the rules. The documentation provided includes a signed plan of care that outlines 
what services are to be performed. The medical records show that the services at issue were provided. The Plan 
has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to 
deny your request. Therefore, we decided that the Plan has to pay for the home health care billed for dates of 
service July 21, 2021, to August 17, 2021.  
 
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 procedure code 24301 for date of service February 1, 2023. 
 
You asked the Plan to pay for procedure code 24301. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed 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. 
 
In this case, the CPT Code Manual definition of code 24301 is muscle or tendon transfer, any type, upper arm 
or elbow, single (excluding 24320-24331) 
 
We find that CPT code 24301 is not supported in the medical record. Specifically, the operative report did not 
include documentation of a single muscle or tendon transfer of any type of the upper arm or elbow; therefore, 
code 24301 cannot be verified.  
 Based on this information, we decided that Medicare rules for coverage of procedure code 24301 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 24301 for date of service 
February 1, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve the shank foot system with vertical loading pylon (L5987) and 
axial rotation unit (L5984)  
 
You asked the Plan to pre-approve shank foot system with vertical loading pylon and axial rotation unit . You 
say that the items are medically necessary. The Plan denied your request. The Plan says that the items are not 
medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that coverage is extended only if there is sufficient 
clinical documentation of functional need for the technologic or design feature of a given type of foot. This 
information must be retained in the treating practitioner's or prosthetist's files. 
 
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 shank foot system with vertical loading 
pylon and axial rotation unit. Our reviewer says that the items are medically necessary. Our physician reviewer 
found the enrollee is a K3 ambulator and entitled to these components. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of shank foot system with vertical loading pylon and axial rotation unit have been 
met. Therefore, we decided that the Plan has to pre-approve the shank foot system with vertical loading pylon 
(L5987) and axial rotation unit (L5984)   
 
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 pay for physician services (99223) provided on September 14, 2022 
to September 15, 2022. 
 
You asked the Plan to pay for the physician services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the documentation does not support the billed 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, the CPT Code Manual definition of code 99223 is initial hospital care, evaluation and management 
of a patient, requiring a comprehensive history, a comprehensive examination, and medical decision making of 
high complexity. 
 
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 physician services. Our reviewer says that the records do 
not support the billed code. Our reviewer found the documentation does not reflect a comprehensive history or 
exam to support billing code 99223. 
 
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 physician services have not been met. Therefore, we decided that the Plan 
does not have to pay for physician services (99223) provided on September 14, 2022 to September 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an out-of-network specialist office visit 
provided on January 16, 2023. 
 
You asked the Plan to waive the copayment for an out-of-network specialist office visit. 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 $65 
copayment for out-of-network physician/practitioner services/specialist. 
 
You have been asked to pay a $65 copayment for an out-of-network specialist office visit. This item/service 
falls within the out-of-network physician/practitioner services/specialist 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 an out-of-network specialist office visit provided on January 16, 
2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with an anticancer regimen comprising Mvasi 
(Q5107) and Doxil (Q2050). 
 
You asked the Plan to pre-approve treatment with Mvasi and Doxil. You say that the requested regimen is a 
medical necessity for the enrollee. The Plan denied your request. The Plan says the requested drugs have been 
prescribed for an off-label, not medically accepted use. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 treatment with Mvasi and Doxil. Our 
reviewer says that the requested drug regimen is not medically reasonable and necessary in this case. Our physician reviewer found that the requested use of Mvasi and Doxil is not FDA-approved for the enrollees 
diagnosis. The use is not supported by one of the major drug compendia or by clinical research that appears in a 
Medicare-approved medical journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of treatment with Mvasi and Doxil have not been met. Therefore, we decided that 
the Plan does not have to pre-approve treatment with an anticancer regimen comprising Mvasi (Q5107) and 
Doxil (Q2050).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99232-25 billed for date of service 
November 20, 2022. 
 
You asked the Plan to pay for the billed services. You say that modifier 25 was billed. The Plan denied your 
request. The Plan says an appropriate modifier was not billed. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We find that CPT code 99232 was billed with the 25 modifier, which is used in association with a minor 
surgical procedure. However, procedure code 33274 is a major surgical procedure. Based on this information, 
we decided that Medicare rules for coverage of the billed services have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure code 99232-25 billed for date of service November 20, 2022.