Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure codes 22590, 22600, 63001, 
22842, 22614, and 20931. We decided that the Plan does not have to pay for the services described by 
procedure codes 20930 and 20936.  
 
You asked the Plan to pay for the surgery services billed for date of service August 28, 2023.  You say that 
medical records were provided. The Plan says that the codes are bundled and not separately payable. 
 
We decided that the Plan has to pay for the services described by procedure codes 22590, 22600, 63001, 
22842, 22614, and 20931.  
 
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. Specifically, the Plan did not make an appeal decision for the codes listed in this 
section. The Plan is not allowed to reopen any determinations while an appeal is pending and must issue a 
determination on all appealed services within the appeal time frame. As the Plan forfeited its opportunity to 
provide a denial rationale for these services, we find that the denial of payment is not supported.  Therefore, we 
decided that the Plan has to pay for the services described by procedure codes 22590, 22600, 63001, 22842, 
22614, and 20931.  
 
We also decided that the Plan does not have to pay for the services described by procedure codes 20930 
and 20936. 
 
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 the procedure codes are not separately payable. Based on this information, we decided that 
Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for 
the services described by procedure codes 20930 and 20936. 
 
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 procedure codes 99232 and 99233 billed for dates of service 
March 8, 2023, to March 9, 2023. 
 
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 the billed codes are not supported. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 99232 and 99233 is not supported in the medical record. The documentation submitted 
did not include medical records for the dates of service at issue. Based on this information, we decided that 
Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure codes 99232 and 99233 billed for dates of service March 8, 2023, to March 9, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 continuous glucose monitor (CGM).  
You asked the Plan to pre-approve a CGM. You say that this CGM is medically necessary. The Plan denied 
your request. The Plan says the medical criteria for a CGM have not been approved. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin. 
Based on this information, we decided that Medicare rules for coverage of a CGM have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 2 continuous glucose 
monitor (CGM).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99285 for date of service August 9, 2022. 
 
You asked the Plan to pay for procedure code 99285. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable as 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. 
 
We find that CPT code 99285 is not payable as billed. Specifically, this service was billed with diagnosis code 
R079 (chest pain, unspecified). However, the diagnosis is missing laterality detail. A more specific diagnosis 
code is available to support the services rendered. Based on this information, we decided that Medicare rules 
for coverage of procedure code 99285 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code 99285 for date of service August 9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device and related supplies 
provided on July 25, 2023. 
 
You asked the Plan to pay for the billed services. 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.  
 
 
 We looked at the file and the rules. The claim shows the services at issue were provided in an outpatient 
hospital facility. Although the services 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 and related supplies provided on July 25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient surgery provided on June 27, 
2023. 
 
You asked the Plan to waive the copayment for the outpatient surgery. You say that the cost share is wrong. 
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 $295 
copayment for Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers. 
 
You have been asked to pay a $295 copayment for the outpatient surgery. This item/service falls within the Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 
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 the outpatient surgery provided 
on June 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pegfilgrastin and IV therapy provided on June 24, 2022. 
 
You asked the Plan to pay for pegfilgrastin and IV therapy. You say that this was medically necessary. The 
Plan denied your request. The Plan says routine care related to the study is not covered. 
 
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of 
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as 
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in 
Original Medicare and the plan cost-sharing for the same services. 
 
In this case, you asked the Plan to pay for pegfilgrastin and IV therapy as part of a clinical trial. The Plan does 
not cover routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not 
have to pay for pegfilgrastin and IV therapy provided on June 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (E0675) provided from 
January 31, 2023, to February 22, 2023. 
 
You asked the Plan to pay for the pneumatic compression device. The Plan denied your request. The Plan says 
the coverage criteria are not met. 
 
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. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 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 (E0675) provided from January 31, 2023, to February 22, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hyaluronan or derivative, Orthovisc, for intra-articular 
injection, per dose (J7324). 
 
You asked the Plan to pre-approve Orthovisc injection. You say that the medical records provided support the 
necessity of the services in dispute. The Plan denied your request. The Plan says Osteoarthritis of the hips 
M16.0 is not an FDA approved reason to get this type of injection. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 Orthovisc injection. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found Osteoarthritis of the hips is not an FDA approved reason to get this type of injection. 
The review has determined that the requested use of Hyaluronan or derivative, Orthovisc, for intra-articular injection of the hip is not FDA-approved for the enrollees diagnosis. Its use is not supported by one of the 
major drug compendia or by clinical research that appears in a CMS-approved medical journal (see appendix 
for list of CMS-approved journals). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Orthovisc injection have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Hyaluronan or derivative, Orthovisc, for intra-articular injection, per dose (J7324).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a chiropractic office visit provided on June 
20, 2023. 
 
You asked the Plan to waive the copayment for a chiropractic office visit. You say that the cost share is wrong. 
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 $20 
copayment for chiropractic services. 
 
You have been asked to pay a $20 copayment for a chiropractic office visit. This item/service falls within the 
chiropractic services 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 a chiropractic office 
visit provided on June 20, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the endoscopic procedure provided on June 
01, 2023. 
 
You asked the Plan to waive the copayment for the endoscopic procedure. You say that you were not charged 
this cost share in the past. 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 $275 
copayment for outpatient surgery and other medical services provided at hospital outpatient facilities.  
You have been asked to pay a $275 copayment for the endoscopic procedure. This item/service falls within the 
outpatient surgery and other medical services provided at hospital outpatient facilities benefit category. This 
means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayment for the endoscopic procedure provided on June 01, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency department visit provided 
on August 23, 2023. 
 
You asked the Plan to waive the copayment for the emergency department visit. You say that you were told 
that you would not be charged for leaving. 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 $90 
copayment for emergency care. 
 
You have been asked to pay a $90 copayment for the emergency department visit. This item/service falls 
within the emergency care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. However, since the allowed amount is less than the standard copayment, you only owe 
$70.93. Therefore, we decided that the Plan does not have to waive the copayment for the emergency 
department visit provided on August 23, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for podiatry services provided on September 26, 2023. 
 
You asked the Plan to pay for podiatry services. You say that you were unaware you needed an approval. 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 podiatry services 
provided on September 26, 2023.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve the repeat administration of Zilretta. 
 
You asked the Plan to pre-approve the medication. You say that the continued treatment is medically 
necessary. The Plan denied your request. The Plan says that you do not meet the criteria for the continued 
treatment of Zilretta.  
 
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 the medication. Our reviewer says that 
the elements of the coverage criteria are satisfied. Our physician reviewer found the Food and Drug 
Administration (FDA) has stated that the requested drug is indicated as an intraarticular injection for treatment 
of osteoarthritis-related knee pain.  The record indicates that you had favorable efficacy from the previous 
injection. The current label does not indicate that there is a prohibition against repeat administration. 
 
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 been met. Therefore, we decided that the Plan has to pre-
approve the repeat administration of Zilretta.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and related supply 
allowance. 
 
You asked the Plan to pre-approve the CGM and related supply allowance. You say that the enrollee has been 
able to decrease the number of medications they take and the CGM will help monitor their glucose. The Plan 
denied your request. The Plan says the Medicare criteria was not met. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 the CGM and related supply allowance. 
Our reviewer says that the CGM coverage criteria was not met. Our physician reviewer found that although the 
CGM has helped the enrollee control blood sugars and diet, the enrollee is not having low blood sugars and 
insulin is not being used now so the coverage criteria for a CGM requires insulin use or low blood sugars are 
not met. This does not mean that the CGM is not helpful for this enrollee; it does mean that coverage criteria 
are 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 CGM and related supply allowance have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and related supply 
allowance.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bupivacaine (J3490) provided on September 21, 2023. 
 
You asked the Plan to pay for bupivacaine. You say that this was a medically necessary part of treatment. The 
Plan denied your request. The Plan says this bupivacaine is a local anesthetic agent that cannot be separately 
reimbursed from the surgical procedure. 
 
The Plan must follow Medicare rules. Medicare rules say that intra-operative services that are normally a usual 
and necessary part of a surgical procedure are included in the global surgical package payment so are not 
separately paid.  
 
We looked at the file and Medicare rules. Bupivacaine is a local anesthetic which is a usual and necessary part 
of the surgical procedure; therefore, it is not separately payable from the global surgical package for surgical 
code 27096-RT. Based on this information, we decided that Medicare rules for coverage of bupivacaine have 
not been met. Therefore, we decided that the Plan does not have to pay for bupivacaine (J3490) provided on 
September 21, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a thyroidectomy (60240). 
 
You asked the Plan to pre-approve a thyroidectomy. 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 thyroidectomy. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found you are now a low risk surgery given your diabetes and your poor functional status that 
has required stopping chemotherapy for colon cancer; it would be prudent to do a fine needle aspiration (FNA) 
to risk stratify you and then be able to better understand the risks of surgery verse the risks of observation. Without an FNA, this cannot be done well and given the inherent risks of a surgical procedure in 
you, a thyroidectomy cannot be said to be appropriate at this time. 
 
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 thyroidectomy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a thyroidectomy (60240).