Persius/hicric huggingface dataset:
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Zilretta (J3304). 
 You asked the Plan to pre-approve Zilretta. You say that this is medically necessary for the enrollee's treatment. 
The Plan denied your request. The Plan says the enrollee has not tried and failed at least two intra-articular 
steroids and simple analgesics. 
 
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 Zilretta. Our reviewer says that the step 
therapy criteria have not been met. Our physician reviewer found the provided records do not indicate that the 
enrollee has tried and failed the preferred drugs. The reviewer also found that there is no documentation 
provided indicating that the Plans required drugs would likely be less effective and/or likely have adverse 
effects for the enrollee. Therefore, the reviewer found that the step therapy criteria have not been 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 Zilretta have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Zilretta (J3304).
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for G0453. We decided that the Plan does not have to pay for 95937 and 
95940.   
You asked the Plan to pay for procedure codes 95937, 95940, and G0453 rendered on June 22, 2023. You say 
that this should be paid for. The Plan says that the records do not support the services billed. 
 
We decided that the Plan has to pay for G0453.  
 
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 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 for G0453. Our reviewer says that the record states that 
the remote monitoring was performed for two hours and twenty minutes. 
 
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 item/service at issue have been met. Therefore, we decided that the Plan has 
to pay for G0453.  
 
We also decided that the Plan does not have to pay for 95937 and 95940. 
 
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 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 for 95937 and 95940. Our reviewer says that 95940 is 
not supported. The record states that remote intraoperative monitoring was performed. There is no 
documentation of the monitoring physician being present in the operating room. Additionally, 95937 is not 
supported. The record states that this code was reported for train of four testing. According to coding rules, this 
is not a separately reportable service. 
 
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 item/service at issue have not been met. Therefore, we decided that the Plan 
does not have to pay for 95937 and 95940. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), a panoramic 
radiographic image (D0330), an intraoral complete series of radiographic images (D0210), and oral/facial 
photographic images (D0350 x2) provided on October 24, 2023, by an out-of-network provider. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered. The Plan denied 
your request. The Plan says the dental services were received from an out-of-network provider and are not 
covered by your supplemental benefits.  
 
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 record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for a comprehensive oral evaluation (D0150), a panoramic radiographic image (D0330), an intraoral 
complete series of radiographic images (D0210), and oral/facial photographic images (D0350 x2) provided on 
October 24, 2023, by an out-of-network provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI).  
 
You asked the Plan to pre-approve magnetic resonance imaging (MRI). You say that you would like to request 
reconsideration of the denied MRI and that the services requested are medically necessary. The Plan denied 
your request. The Plan says the criteria for approval have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
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 magnetic resonance imaging (MRI). 
Our reviewer says that the service is not medically necessary. Our physician reviewer found the medical 
necessity of the requested MRI lumbar spine has not been established in the submitted records. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of magnetic resonance imaging (MRI) have not been met. Therefore, we decided 
that the Plan does not have to pre-approve magnetic resonance imaging (MRI).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on October 25, 2023. 
 
You asked the Plan to pay for lab testing. You say that the 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 Plan had network providers available who were capable of providing the items/services at issue in this appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) 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 lab testing provided on October 25, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the SNF care provided by an in-network 
provider from November 26, 2022, to January 10, 2023.  
 
You asked the Plan to waive the copayment for the SNF care. You say that you feel that the charges are 
incorrect. 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 $0 
copayment per day for days 1-20, and a $188 copayment per day for days 21-100, for in-network Medicare-
covered SNF stays.   
 
 You have been asked to pay a $4,066 copayment for the SNF care because you met your maximum out-of-
pocket during the processing of the claim. This item/service falls within the skilled nursing facility (SNF) 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. 
Therefore, we decided that the Plan does not have to waive the copayment for the SNF care provided by an in-
network provider from November 26, 2022, to January 10, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on October 20, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim is not 
payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that the type of bill is required on the claim. This 
four-digit alphanumeric code gives three specific pieces of information after a leading zero. Medicare will 
ignore the leading zero. Medicare will continue to three specific pieces of information. The second digit 
identifies the type of facility. The third classifies the type of care. The fourth indicates the sequence of this bill in this particular episode of care. It is referred to as a frequency code. 
 
We looked at the file and Medicare rules. In this case, the claim was billed with frequency code 8, which 
indicates that the prior claim should be voided or canceled. However, as the Plan has already voided/canceled 
the prior claim, the use of frequency code 8 is not appropriate in this case. Based on this information, we 
decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan 
does not have to pay for the services provided on October 20, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital services provided on 
September 21, 2023, to September 22, 2023. 
 
You asked the Plan to waive the copayment for the inpatient hospital services. 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 $360 
copayment for inpatient hospital services. 
 
You have been asked to pay a $360 copayment for the inpatient hospital services. This item/service falls within 
the inpatient hospital 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 the inpatient 
hospital services provided on September 21, 2023, to September 22, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 96401 billed for date of service October 19, 
2023. 
 
You asked the Plan to pay for procedure code 96401. You say that these services were medically necessary and 
are supported as billed. The Plan denied your request. The Plan says it is not appropriate to report this code for 
the services provided. 
 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 96401 is chemotherapy administration, subcutaneous or intramuscular; non-hormonal anti-neoplastic. The 
rules say it is not appropriate to use this code when reporting certain drugs. 
 
We find that CPT code 96401 is not supported in the medical record. Specifically, this service is a 
chemotherapy administration code which was reported on the same claim as code J0897 (denosumab, 1 mg 
injection). The rules say that chemotherapy administration codes should not be used with denosumab. Instead, 
providers should report CPT code 96372. Based on this information, we decided that Medicare rules for 
coverage of procedure code 96401 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 96401 billed for date of service October 19, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous positive airway pressure (CPAP) device 
(E0601) provided on August 25, 2023. 
 
You asked the Plan to pay for the continuous positive airway pressure (CPAP) device (E0601). You say that 
the item 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 Plan had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) 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 continuous positive airway pressure (CPAP) device (E0601) provided on August 25, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 27, 2023. 
 
You asked the Plan to pay for the lab services. You say that this testing was performed at the request of a 
network physician. The Plan denied your request. The Plan says you billed with an incorrect place of service on 
the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on July 27, 2023.
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 despite aggressive bilevel therapy patient 
remains clinically hypercapnic. The Plan denied your request. The Plan says based on Medicare guidelines, the 
non-invasive ventilator requested does not meet the requirements for approval. 
 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. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not 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 a home ventilator. Our reviewer says 
that a home ventilator is not medically necessary. Our physician reviewer found this patient has diagnoses of 
COPD and pulmonary fibrosis with multiple recent hospitalizations for shortness of breath.  There is no 
diagnosis of thoracic restrictive disease or neuromuscular disease. Our reviewer found that there are no 
pulmonary function tests to confirm airways obstruction and assess severity. The ordering providers appeal 
note mentions an arterial blood gas with a partial pressure of carbon dioxide (PaCO2) of 63, but full results are 
not provided. If this patient has severe COPD and chronic carbon dioxide retention, they may benefit from 
BiPAP with volume assurance as an outpatient. Our physician reviewer also found that the records do not show 
this has been tried 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 primary and backup home ventilator. 
 
You asked the Plan to pre-approve the ventilators. You say that the enrollee requires a ventilator at their 
bedside to wear throughout the night. You say that the enrollee requires a second ventilator to be placed on 
their wheelchair for daytime mouthpiece ventilation as well as noninvasive ventilation required throughout the day. The Plan denied your request. The Plan says two home ventilators set in pressure mode with Auto-EPAP 
(AE) that could be delivered by bilevel positive airway pressure (BiPAP) are not covered. 
 
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. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not 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 ventilators. Our reviewer says that 
the requested ventilators are not medically necessary. Our physician reviewer found the enrollee is complaint 
with bilevel positive airway pressure (BIPAP) and has compensated hypercapnic respiratory failure. There is 
no evidence of failure of BIPAP and during hospitalization, improved with continuous positive airway pressure 
(CPAP) therapy. The documentation does not support home ventilator at this time. Therefore, the reviewer 
found that the requested ventilators are 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 the ventilators have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a primary and backup home ventilator.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency care services (99284, 70450, 72125, 72131, 
71046, 93005, 96372 and J1885) provided on March 31, 2023. 
 
You asked the Plan to pay for emergency care services. You say that these services were necessary and should 
be paid. The Plan denied your request. The Plan says this claim must first be processed by the enrollee's 
primary health plan. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed the 
provider to bill the enrollee's primary plan. As the secondary insurer, the Plan cannot be held responsible for 
emergency care services until the primary insurer has denied the claim for these services. Therefore, we 
decided that the Plan does not have to pay for emergency care services (99284, 70450, 72125, 72131, 71046, 
93005, 96372 and J1885) provided on March 31, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services are medically necessary. The 
Plan denied your request. The Plan says the enrollee's care needs are being met in the current facility. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
 
 
 
 
 
 
 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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has ongoing acute medical issues and still requires acute care services 
before transitioning to a lower level of care. The enrollee continues to receive acute care services, and these 
have not been denied. The medical record does not indicate that the enrollee requires services that they are not 
currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are 
not satisfied. The requested service cannot be recommended. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service June 15, 
2023. 
 
You asked the Plan to pay for procedure code 99100. You say that this code was requested by the surgeon to 
aid the patient with pain management. The Plan denied your request. The Plan says procedure code 99100 is 
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 code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service June 15, 2023.