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

 
We decided that the Plan does not have to pre-approve repeat medial branch blocks (MBBs). 
 
You asked the Plan to pre-approve repeat MBBs. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the requested services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a second confirmatory diagnostic facet joint 
procedure is considered medically reasonable and necessary when after the first diagnostic facet joint 
procedure, there was a consistent positive response of at least 80% relief of primary (index) pain. 
 
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 repeat MBBs. Our reviewer says that 
the documentation does not support that the requested services are medically reasonable or necessary. Our 
physician reviewer found the enrollee has a history of chronic low back pain. The enrollee has been treated 
with medications and has undergone spinal injections including medial branch blocks and caudal epidural steroid injections. The enrollee underwent a bilateral MBBs on May 1, 2023, at L3-L5 with 50% relief for 
approximately one month. The enrollee notes current pain level is seven out of 10. Since the previous services 
did not provide at least 80% relief, the requested repeat services are not covered. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of repeat MBBs have not been met. Therefore, we decided that the Plan does not 
have to pre-approve repeat medial branch blocks (MBBs).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the pneumatic compression device provided on November 28, 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 November 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dental services. 
 
You asked the Plan to pre-approve the dental services. You say that you would like to request reconsideration 
of the denied authorization. The Plan denied your request. The Plan says your benefit for the requested item or 
service 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 Plan's 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 benefit for the requested item or service was exhausted on date of service March 15, 2023. 
Therefore, we decided that the Plan does not have to pre-approve the dental services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical placement of implant body: endosteal implant 
(D6010 x6), and sinus augmentation with bone or bone substitutes via a lateral open approach (D7951 x2). 
 
You asked the Plan to pre-approve surgical placement of implant body and sinus augmentation. You say that 
sinus augmentation for UA & UL are recommended to have enough bone structure to restore patient with 
implants on sites # 3, 14, 18, 19, 30 & 31. Teeth # 30 & 31 were extracted on 01/17/2022. Other teeth extracted 
more than 3 years ago. These procedures are recommended to preserve the site and occlusal plane for further 
implant held restorations with a favorable prognosis. The Plan denied your request. The Plan says the requested 
dental implants do not meet the criteria. The Plan also says that the sinus augmentation with bone or bone 
substitutes via a lateral open approach is not listed as a covered benefit. 
 
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.  
 
The sinus augmentation with bone or bone substitutes via a lateral open approach or services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve sinus 
augmentation with bone or bone substitutes via a lateral open approach (D7951 x2). 
 
The Plan covers surgical placement of implant body and sinus augmentation when the services are medically 
necessary and reasonable.  
 
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 surgical placement of implant body and 
sinus augmentation. Our reviewer says that the surgical placement of implant body: endosteal implant is not 
medically necessary. Our physician reviewer found in this instance, at the time of the service request, teeth 
#5/28, #12/21, and #13/20 were in contact. The six points of posterior contact fall short of the required eight 
under the Plan provisions. Given the clinical situation at the time of the request, the Plan criteria would not be 
met for the implants requested.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of surgical placement of implant body and sinus augmentation have not been met. 
Therefore, we decided that the Plan does not have to pre-approve surgical placement of implant body: 
endosteal implant (D6010 x6), and sinus augmentation with bone or bone substitutes via a lateral open 
approach (D7951 x2).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve  an automatic blood pressure machine (A4670).  
 
You asked the Plan to pre-approve  an automatic blood pressure machine. You say that by having the blood 
pressure machine, you will be able to monitor your blood pressure in a timely manner and this will prevent you 
from having hospital visits. You will also benefit from having a blood pressure machine because you will be 
able to track the fluctuations of your blood pressure and find ways to lower it without the help of more 
medications. The Plan denied your request. The Plan says this device is not covered for non-ESRD patients. 
 
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 an automatic blood pressure machine. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found that a home blood pressure machine is covered only for enrollees with end-stage kidney function by the Medicare covered durable medical devices. You do not have end-stage kidney 
function and thus this device is not covered. 
 
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 automatic blood pressure machine have not been met. Therefore, we decided 
that the Plan does not have to pre-approve  an automatic blood pressure machine (A4670).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services for date of service February 10, 
2022, to March 7, 2022. 
 You asked the Plan to pay for the home health services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the NOA was not received timely. As such, this final claim was 
correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is January 11, 2022. The NOA was not received by the Plan until October 26, 
2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for the home health services for 
date of service February 10, 2022, to March 7, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from March 19, 2022, to 
April 17, 2022. 
 You asked the Plan to pay for the home health services. You say that there is a NOA on file, so this claim 
should be paid. The Plan denied your request. The Plan says the NOA was not received timely. As such, this 
final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is February 17, 2022. The NOA was not received by the Plan until August 17, 
2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
from March 19, 2022, to April 17, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that you are upset because your equipment is 
being taken away from you and you cannot breathe without it at night. The Plan denied your request. The Plan 
says records show the NIV is going to be used only in Bi-level PAP mode called AVAPS. Under Medicare, 
ventilators used to provide CPAP or bi-level CPAP therapy are not reasonable and necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
 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 home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found you have a diagnosis of COPD and 
obstructive sleep apnea. The FEV1 is 45% of predicted. You have had a recent hospitalization for pneumonia, 
and a trilogy ventilator was provided on February 8, 2023. The records do not include an arterial blood gas, 
done while stable, to document chronic CO2 retention. If that is present, you may benefit from BiPAP with 
AVAPS. The records do not document that this has been tried and failed as an outpatient. Medicare does not 
cover a home ventilator when used at settings that can be provided with BiPAP. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the requested device is medically necessary, 
as the enrollee has had frequent hospitalization. The Plan denied your request. The Plan says the records show 
that the enrollee's noninvasive ventilator is going to be used exclusively in a bi-level PAP mode. The ventilator 
was ordered in a mode called volume assured pressure support (VAPS), and this can be achieved with bi-level 
devices such as a BiPap machine. The records also do not show that the enrollee failed BiPap therapy while 
hospitalized. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 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 home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has COPD and was 
recently hospitalized with pneumonia. There are no pulmonary function test results in the record. There is no 
ABG done while stable, to document chronic CO2 retention. If that is present, the enrollee may benefit from 
BiPAP with AVAPS during sleep. Medicare does not cover a home ventilator when used at settings that can be 
provided with BiPAP. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Entyvio. 
 You asked the Plan to pre-approve Entyvio. You say that the enrollee would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says the step therapy requirements have not been 
met.  
 
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 Entyvio. Our reviewer says that 
Entyvio is not medically necessary. Our physician reviewer found that the enrollee has not tried and failed the 
required drugs Remicade, Inflectra, infliximab, or Stelara. There is no documentation indicating that the Plan's 
required drugs would likely be less effective or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Entyvio have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Entyvio.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99215 for date of service October 26, 2022. 
 
You asked the Plan to pay for procedure code 99215. 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 99215 is office or other outpatient visit for the evaluation 
and management of an established patient, which requires a medically appropriate history and/or examination 
and high level of medical decision making. When using time for code selection, 40-54 minutes of total time is 
spent on the date of the encounter. 
 
 
 We find that CPT code 99215 is not supported in the medical record. Specifically, the documentation does not 
include the total time spent on this service. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99215 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99215 for date of service October 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code J3490 for date of service January 25, 2023. 
 
You asked the Plan to pay for procedure code J3490. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services billed are 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 CPT code. 
 
In this case, the CPT Code Manual definition of code J3490 is unclassified drugs. 
 
We find that CPT code J3490 is not supported in the medical record. Specifically, this service was provided 
within the global surgery period of a surgery procedure. Without an appropriate modifier, code J3490 is not 
payable as billed. Based on this information, we decided that Medicare rules for coverage of procedure code 
J3490 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code J3490 
for date of service January 25, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 22800 and 20930 billed for date of service 
October 19, 2022. 
 
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 cannot be verified. 
 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 22800 is arthrodesis, posterior, for spinal deformity, with 
or without cast; up to 6 vertebral segments. We find that CPT code 22800 is not supported in the medical 
record. We find that procedure code 20930 has a status indicator of B on the Physician Fee Schedule. This 
means that procedure code 20930 is not separately payable. 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 codes 22800 and 20930 billed for date of service October 19, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes A4253 and A4259 billed for date of service 
July 15, 2021, to October 18, 2021.  
 
You asked the Plan to pay for procedure codes A4253 and A4259. You say that the services were medically 
necessary. The Plan denied your request. The Plan says the number of units billed exceeds the maximum 
allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT codes A4253 and A4259 is 1. The MAI value for this code is 3. You billed 4 
units of code A4253 on each date of service, and 2 units of code A4259 for each date of service, exceeding the 
MUE. The documentation does not show that the excess units were provided, correctly coded, or medically 
necessary. 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 A4253 and A4259 billed for date 
of service July 15, 2021, to October 18, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a mastopexy/breast lift (14001, 14301, 19316). 
 You asked the Plan to pre-approve a mastopexy/breast lift. You say that you want the Plan to approve this 
service. The Plan denied your request. The Plan says mastopexy/breast lift is not one of the covered 
reconstructive procedures and is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not 
covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are 
coverable.   
 
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 mastopexy/breast lift. Our reviewer 
says that the service is not medically necessary. Our reviewer found the record indicates that the enrollee has 
had weight loss causing excessive skin. The record provided does not establish that the requested procedure is 
for the prompt repair of accidental injury or to improve the functioning of a malformed body member. The 
record does not indicate that the requested procedure is being performed for a condition enumerated in the 
coverage criteria. 
 
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 mastopexy/breast lift have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a mastopexy/breast lift (14001, 14301, 19316).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve minimally invasive sacroiliac (SI) joint fusion. 
 
You asked the Plan to pre-approve minimally invasive SI joint fusion. You say that you are in severe pain and 
need this surgery. The Plan denied your request. The Plan says minimally invasive sacroiliac joint fusion is not 
medically necessary. In this case, x-rays confirm moderate bilateral hip osteoarthrosis. Additionally, the 
records show that there, "some degree that your symptoms may persist due to musculoskeletal/arthritic pain 
and your history of chronic nerve damage from preoperative nerve compression." You are status post L2-S1 
fusion in April of 2021. 
 
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 minimally invasive SI joint fusion. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no clear cause of your back pain. You have had previous fusion of 
the lumbar spine. There is no SI joint instability, fracture, or lesion. SI joint fusion for degenerative back pain is 
experimental. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of minimally invasive SI joint fusion have not been met. Therefore, we decided 
that the Plan does not have to pre-approve minimally invasive sacroiliac (SI) joint fusion.