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

 
We decided that the Plan does not have to pay for codes 93005 and 93041 billed for date of service November 
13, 2022. 
 
You asked the Plan to pay for codes 93005 and 93041. You say that these are covered codes and these services 
were medically necessary. The Plan denied your request. The Plan says these two codes are not separately 
payable. 
 
The Plan must follow Medicare rules. Medicare 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, codes 93005 and 93041 have a status indicator of Q1, meaning that they are STV-packaged 
services. These two codes were billed on the same claim with code 99285.  Code 99285 has a status indicator 
of V.  This means that the STV-packaged codes in dispute (codes 93005 and 93041) are not separately payable.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of codes 93005 and 93041 have not been met. Therefore, we decided that the Plan does not have to 
pay for codes 93005 and 93041 billed for date of service November 13, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept device. 
 
You asked the Plan to pre-approve an Intracept device. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.  
The Plan follows Medicare rules. Medicare rules say that thermal destruction of the intraosseous BVN will be 
considered medically reasonable and necessary for the treatment of cLBP in patients who meet specific criteria. 
 
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 Intracept device. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found the magnetic resonance imaging 
(MRI) shows disc slippage and facet degenerative joint disease (djd). The cause of the back pain is not clear. 
 
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 Intracept device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an Intracept device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro powered arm brace. 
 
You asked the Plan to pre-approve the brace. You say that this is medically necessary. The Plan denied your 
request. The Plan says experimental and investigational procedures are 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 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 brace. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the MyoPro Orthosis is not known to be effective, based on scientific evidence, professional 
standards and expert opinion, in improving health outcomes. The MyoPro is not the standard of care for this 
enrollee's condition or in widespread use for this enrollee's condition based on scientific evidence. There is 
insufficient evidence in the literature that the MyoPro Orthosis will improve the long term outcomes for this enrollee. There is insufficient evidence in the literature that this device will increase participation in bimanual 
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 the brace have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the MyoPro powered arm brace.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a fixed bridge for teeth numbers 12-15. 
 
You asked the Plan to pre-approve the fixed bridge. You say that you have additional coverage remaining for 
your dental benefit and feel this should be approved. The Plan denied your request. The Plan says that the 
original denial was not reviewed on appeal as the Plan did not make a determination within the required time 
frame. 
 
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's contract clearly indicates that fixed bridges are covered in full up to 
the total maximum allowable of $5000 per year. The Plan has not provided any argument to indicate that the 
requested bridge is not necessary. There is also no evidence that the dental maximum has been met. Without 
any valid denial rationale, we find that the coverage rules for the requested bridge have been, up to the 
maximum $5000 limit. Therefore, we decided that the Plan has to pre-approve a fixed bridge for teeth numbers 
12-15.  
 
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 provided from March 27, 2022, to 
April 25, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the denial. The 
Plan denied your request. The Plan says the claim has not been billed with the correct admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from March 27, 2022, to April 
25, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Rytary. 
 
You asked the Plan to pre-approve Rytary. You say that since the enrollee has started taking Rytary they have 
significantly improved their mobility, gait, and balance without any side effects. The Plan denied your request. 
The Plan says self-administered drugs do not fall under Medicare Part B coverage. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Rytary.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on November 1, 2022. 
 
You asked the Plan to pay for the ambulance services. You say that the medical records provided support the 
need for the ambulance transport. The Plan denied your request. The Plan says this claim does not meet the 
requirements for non-emergency transport. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 ambulance services. Our reviewer says 
that the ambulance service was not medically necessary. Our physician reviewer found the transportation via 
ambulance from an assisted living facility to an extended care facility was not medically necessary.  
 The enrollee did not require the expertise of trained personnel or the equipment available only on an ambulance 
in order to effectuate a safe transport. Transportation could have been provided by other means (stretcher van, 
wheelchair van, private car, taxi) without endangering the enrollee's condition. 
 
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 ambulance services have not been met. Therefore, we decided that the Plan 
does not have to pay for ambulance services provided on November 1, 2022.
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 is medically necessary. The Plan denied 
your request. The Plan says unproven and not medically necessary procedures are not covered by Medicare due 
to insufficient evidence of efficacy. 
 
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 services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the review indicates 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 20930 and 20936 billed for date of service 
October 7, 2022. 
 
You asked the Plan to pay for procedure codes 20930 and 20936. You say that you provided medical records to 
support payment. The Plan denied your request. The Plan says procedure codes 20930 and 20936 are 
considered bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure codes 20930 and 20936 have a status indicator of B on the Physician Fee Schedule. 
This means that procedure codes 20930 and 20936 are not separately payable. Based on this information, we 
decided that Medicare rules for coverage of procedure codes 20930 and 20936 have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure codes 20930 and 20936 billed for date of service 
October 7, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that you are requesting an expedited reconsideration for 
the denial of a SNF admission. The Plan denied your request. The Plan says the request does not meet the 
medical criteria/guidelines for admission to a SNF. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. Evaluating therapists 
recommend daily skilled therapy in a SNF setting however, all inpatient therapy goals have been met except for 
the stair goal. The clinical documentation does not show that you require daily skilled nursing and/or skilled 
therapy on an inpatient basis in a skilled nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Synvisc injection.  
You asked the Plan to pre-approve a Synvisc injection. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that various polymers of hyaluronic acid have been 
approved and marketed as implanted prosthetic devices. 
 
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 Synvisc injection. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found you have multiple other modalities 
available. The request does not meet the criteria of 3 months of conservative therapy. 
 
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 Synvisc injection have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Synvisc injection.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services billed with codes 88341, 88342, 
88381 and 88360 for December 28, 2021. 
 
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 the services are not separately payable. 
 
The Plan must follow Medicare rules. The rules say that the PC and TC for diagnostic services are separately 
payable when furnished in different payment localities. 
 
We looked at the file and Medicare rules. The file shows that the PC and TC were not performed in different 
payment localities. 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 the laboratory services billed 
with codes 88341, 88342, 88381 and 88360 for December 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on July 27, 
2022. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device provided on July 27, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on September 23, 2022, 
through October 3, 2022, and billed with diagnosis code G92.8. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that 
secondary diagnosis G92.8 is supported by the records. The Plan denied your request. The Plan says the 
documentation submitted does not support secondary diagnosis of G92.8. 
 
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 provided with secondary diagnosis code G92.8-Other toxic 
encephalopathy. 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 documentation does not support secondary 
diagnosis of G92.8-Other toxic encephalopathy. Our physician reviewer found the member was alert and 
oriented, awake, cooperative, and followed commands. Although the member appeared to be taking multiple 
medications, there was inconsistent documentation of any significant mental status changes. Therefore, the 
member does not meet the definition criteria for encephalopathy and therefore, the records submitted do not 
support secondary diagnosis code, G92.8-Other toxic encephalopathy due to polypharmacy.  
 
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 on September 23, 2022, through October 3, 2022, and billed with 
diagnosis code G92.8.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bacterial urine culture (87086) provided on October 10, 
2022. 
 
You asked the Plan to pay for the bacterial urine culture. You say that this service was medically necessary and 
is supported in the medical record. The Plan denied your request. The Plan says this claim was not submitted 
with a diagnosis which supports the medical necessity of this service. 
 
The Plan must follow Medicare rules. Medicare rules say that there are certain diagnosis codes which support 
the medical necessity of code 87086. Any codes which are not listed are considered not medically necessary for 
code 87086. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the urine culture have not been met. Specifically, this claim was submitted with a diagnosis code which is not among those codes listed as medically necessary and appropriate for this service. Therefore, we 
decided that the Plan does not have to pay for the bacterial urine culture (87086) provided on October 10, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMs device. 
 
You asked the Plan to pre-approve a CardioMEMs device. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 a CardioMEMs device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there remains a dearth of randomized, blinded clinical studies examining long-term 
clinical outcomes establishing the value of CardioMEMS in patient management. As a result, at this time the 
CardioMEMS system would not be considered medically appropriate and necessary in your clinical management. 
 
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 CardioMEMs device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMs device.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Orencia IV. 
 You asked the Plan to pre-approve Orencia IV. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the requested drug does not meet step therapy criteria. 
 
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 Orencia IV. Our reviewer says that the 
documentation does not support that Our physician reviewer found the enrollee has diagnoses of Systemic 
lupus erythematosus, organ or system involvement unspecified, and Rheumatoid arthritis without rheumatoid 
factor, multiple sites. The documentation does not support that the enrollee has tried and failed Inflectra, 
Infliximab, Remicade, Simponi aria, and/or, Stelara. The documentation does not support that Inflectra, 
Infliximab, Remicade, Simponi aria, and/or, Stelara would likely be less effective and/or likely have adverse 
effects for the enrollee. 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 Orencia IV have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Orencia IV.