Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve hyperbaric oxygen therapy. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the records do not show 30 days of treatment with standard wound therapy. 
 
The Plan must follow Medicare rules. Medicare rules say that services are covered if they are medically 
necessary and meet specific coverage 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 the services. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that the records support that the enrollee is suffering with a Wagner grade 3 ulceration with osteomyelitis 
to the fifth digit on the left side. Between 9/26/23 and 10/22/23, the wound is noted to have not reduced in size 
whatsoever. The guidelines advise that hyperbaric oxygen therapy is appropriate for non-healing wounds that 
are Wagner grade 3, with failure of an adequate course of standard wound therapy. It is noted that the enrollee 
has undergone offloading, wound debridement, wound dressings, IV antibiotics, and oral antibiotics. Despite 
these conservative measures, the wound has not reduced in size. Therefore, the enrollee does meet the criteria 
for this request. 
 
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 services have been met. Therefore, we decided that the Plan has to pre-
approve hyperbaric oxygen therapy.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting reconsideration of denied 
authorization. The Plan denied your request. The Plan says the coverage criteria has not been met.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the most recent therapy session on October 9, 2023, showed that you required 
minimal assistance for transfers and contact guard assistance for bed mobility. When your gait was tested, you 
were able to pivot to a chair with minimal assistance. You do not require treatment by multiple therapies, 
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 
There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81456 billed for date of service March 29, 
2023. 
 
You asked the Plan to pay for procedure code 81456. You say that the NCCI has agreed to change the NCCI 
indicator to One, which would allow payment for these two codes together. The Plan denied your request. The 
Plan says payment for code 81456 is bundled into payment for code 81455. 
 
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 81456 is a column two code to column one code 81455 with a modifier indicator of 0. The column two code is 
therefore not payable. Based on the claim submitted, Medicare billing criteria have not been met. Please note 
that the NCCI indicator change that you reference was not officially implemented until October 1, 2023. This 
date is well after your date of appeal. As a result, the Plan cannot be obligated to bypass this edit. You have the 
right to submit the claim again for additional consideration based on the rule change. Therefore, we decided 
that the Plan does not have to pay for procedure code 81456 billed for date of service March 29, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc.  
You asked the Plan to pre-approve Synvisc. You say that Synvisc is medically necessary. The Plan denied your 
request. The Plan says a trial of Euflexxa 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 Synvisc. Our reviewer says that 
Synvisc 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 Synvisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Synvisc.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on April 19, 2023. 
 
You asked the Plan to pay for an office visit. You say that you are requesting reconsideration for the denied 
claim. 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 an office visit provided 
on April 19, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81456 billed for date of service April 14, 
2023. 
 
You asked the Plan to pay for procedure code 81456. You say that the NCCI has agreed to change the NCCI 
indicator to One, which would allow payment for these two codes together. The Plan denied your request. The 
Plan says payment for code 81456 is bundled into payment for code 81455. 
 
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 81456 is a column two code to column one code 81455 with a modifier indicator of 0. The column two code is 
therefore not payable. Based on the claim submitted, Medicare billing criteria have not been met. Please note 
that the NCCI indicator change that you reference was not officially implemented until October 1, 2023. This 
date is well after your date of appeal. As a result, the Plan cannot be obligated to bypass this edit. You have the 
right to submit the claim again for additional consideration based on the rule change. Therefore, we decided 
that the Plan does not have to pay for procedure code 81456 billed for date of service April 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on May 25, 2023. 
 
You asked the Plan to pay for an office visit. You say that you are requesting reconsideration for the denied 
claim. 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 an office visit provided 
on May 25, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on April 03, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that this testing was 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 laboratory services 
provided on April 03, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81456 billed for date of service February 7, 
2023. 
 
You asked the Plan to pay for procedure code 81456. You say that the NCCI has agreed to change the NCCI 
indicator to One, which would allow payment for these two codes together. The Plan denied your request. The 
Plan says payment for code 81456 is bundled into payment for code 81455. 
 
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 81456 is a column two code to column one code 81455 with a modifier indicator of 0. The column two code is 
therefore not payable. Based on the claim submitted, Medicare billing criteria have not been met. Please note 
that the NCCI indicator change that you reference was not officially implemented until October 1, 2023. This 
date is well after your date of appeal. As a result, the Plan cannot be obligated to bypass this edit. You have the 
right to submit the claim again for additional consideration based on the rule change. Therefore, we decided 
that the Plan does not have to pay for procedure code 81456 billed for date of service February 7, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve neuro-psychological testing to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve neuro-psychological testing. You say that you are requesting 
reconsideration for the denied claim. The Plan denied your request. The Plan says this provider is out-of-
network and authorization was not obtained. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
neuro-psychological testing to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transcatheter mitral valve repair using percutaneous 
annuloplasty. 
 
You asked the Plan to pre-approve transcatheter mitral valve repair using percutaneous annuloplasty. You say 
that you agree with your doctor that the valve replacement would give you a better quality of life as you are 
very limited since being placed on oxygen. The Plan denied your request. The Plan says transcatheter mitral 
valve repair using percutaneous annuloplasty is considered experimental, investigational, and/or unproven for 
the treatment of mitral valve regurgitation (insufficiency). 
 
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 transcatheter mitral valve repair using 
percutaneous annuloplasty. Our reviewer says that the requested transcatheter mitral valve repair using percutaneous annuloplasty is not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the records do not reflect that the degree of mitral stenosis is severe. The request is for off-
label use of a Sapiens 3 valve for native mitral valve stenosis and regurgitation. The documentation is 
inadequate to confirm fulfillment of published CMS guidelines for percutaneous annuloplasty (TMVR). As a 
result, at this time TMVR would not be considered medically reasonable 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 transcatheter mitral valve repair using percutaneous annuloplasty have not been 
met. Therefore, we decided that the Plan does not have to pre-approve transcatheter mitral valve repair using 
percutaneous annuloplasty.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve the therapy services. You say that the additional PT is medically necessary 
for the enrollee.  The Plan denied your request. The Plan says the requested services are not reasonable and 
necessary, and the health Plan has no contractual obligation to cover services that are not covered by Medicare.   
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the enrollee has had 30 sessions of PT and continues to have 
weakness and require assistance with transfers and mobility. However, there is a lack of objective progress 
with continued treatment and the enrollee's standardized tests have not significantly improved as well as motor 
strength. The enrollee does not require the services of a skilled physical therapist. Therefore, the 10 additional 
PT visits are 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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 10 additional physical therapy (PT) visits.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital services provided from February 6, 2023, to 
February 13, 2023. 
 
You asked the Plan to pay for the hospital services. You say that the criteria for inpatient care were met. The 
Plan denied your request. The Plan says these services were correctly denied. 
 
The Plan must follow Medicare rules. Medicare rules say that services provided to incarcerated persons are not 
covered.  These services are indicated by a provider's use of modifier QJ. 
 
In this case, you billed the hospital services in question with modifier QJ, indicating that these services were 
rendered to an incarcerated individual.  Neither Medicare nor the Plan pay for services provided to incarcerated 
persons. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the hospital services have not been met. Therefore, we decided that the Plan does not have to pay 
for hospital services provided from February 6, 2023, to February 13, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental implants services. 
 
You asked the Plan to pre-approve the dental services. You say you need this dental work. The Plan denied 
your request. The Plan says your $1,000 dental annual maximum allowance has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your $,000 annual dental maximum allowance for covered dental services was exhausted on date of 
service April 11, 2023. Therefore, we decided that the Plan does not have to pre-approve dental implants 
services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve RFA. 
 
You asked the Plan to pre-approve genicular nerve RFA. You say that the requested genicular nerve RFA is 
medically necessary. The Plan denied your request. The Plan says genicular nerve RFA is considered 
experimental or investigational. 
 
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 genicular nerve RFA. Our reviewer 
says that the requested genicular nerve RFA is not considered medically reasonable and necessary. Our 
physician reviewer found that the enrollee was being treated for left knee joint disorders and right knee joint 
disorders. The enrollee presented with bilateral knee pain. The exam reveals bilateral knee pain that persists. 
There is crepitus upon movement. There is tenderness to palpation noted. However, detailed documentation is not evident regarding formal diagnostic studies corroborating pathology of the bilateral knees that could benefit 
from the requested procedure/injection. Moreover, limited published, large-scale, long-term peer-reviewed 
literature shows this request to be an effective and/or safe treatment for the noted pathology. Further studies are 
needed to corroborate this treatment modality is as safe and effective as other standard treatments for the 
bilateral knees. No compelling rationale is presented, or extenuating circumstances noted to support the 
medical necessity of this request as an exception to guidelines. Therefore, the requested genicular nerve RFA 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 genicular nerve RFA have not been met. Therefore, we decided that the Plan 
does not have to pre-approve genicular nerve RFA.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued chiropractic manipulative treatments (98940). 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says you do not meet criteria for coverage of the 
requested services.  
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover chiropractic maintenance 
care.  
 
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 these services. Our reviewer says that 
you do not meet criteria for coverage of the requested services. Our physician reviewer found that based on the 
medical records provided, the documentation from the chiropractor does not indicate an objective overall 
change in your rated pain level and the records report no need for specific follow-up visits, only to return as 
needed. The rules say that Medicare does not cover chiropractic maintenance care. When further clinical 
improvement cannot be reasonably expected from ongoing care, the care is considered maintenance. The 
records in this case appear to indicate that chiropractic maintenance care has been 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve continued chiropractic manipulative treatments (98940).