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

 
We decided that the Plan has to pay for procedure code J7325. We decided that the Plan does not have to pay 
for procedure code 99214-25.  
 
You asked the Plan to pay for procedure codes 99214-25 and J7325 provided on April 10, 2023. You say that 
you would like the Plan to reconsider their denial of payment. The Plan says that the services are not covered as 
billed. 
 
We decided that the Plan has to pay for procedure code J7325.  
 
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. In this case, the Plan has not provided enough evidence to support the denial of 
payment for procedure code J7325 based on Medicare criteria. The Plan provided no regulations showing that 
the National Drug Code (NDC) is required on the claim for payment to be made. The reporting of the NDC 
number is not required on Medicare claims unless the beneficiary is dually eligible for Medicare and Medicaid. 
The Plan has provided no evidence that the enrollee is dually eligible for Medicare and Medicaid. Furthermore, 
the NDC number that was reported on the claim is the correct NDC for procedure code J7325 (Synvisc). 
Therefore, we decided that the Plan has to pay for procedure code J7325.  
 
We also decided that the Plan does not have to pay for procedure code 99214-25. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We find that CPT code 99214-25 is not supported in the medical record. The office visit at issue was billed 
with modifier 25, which is used to report a significant, separately identifiable Evaluation and Management 
(EM) service by the same physician or other qualified health care professional on the same day of a procedure 
or other service. There is no documentation of any significant, separately identifiable evaluation unrelated to 
the treatment provided to the enrollee on this date of service. Therefore, we decided that the Plan does not have 
to pay for procedure code 99214-25. 
 
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 pay for the wound care supplies provided on June 15, 2023, by an 
OON provider.  
 
You asked the Plan to pay for the wound care supplies. You say that you are requesting reconsideration of the 
denied claim. The Plan denied your request. The Plan says the service was not authorized. 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 contract says the enrollees POS benefit only applies to 
covered routine dental services. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the wound care supplies provided on June 15, 
2023, by an OON provider.
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 December 
28, 2022. 
 
You asked the Plan to pay for procedure code 99100. You say that payment was denied incorrectly based on a 
provider type issue. 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 December 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the protective under pad (T4537), folding walker (E0143), 
transport chair (E1038), and sales tax (S9999). 
 
You asked the Plan to pay for the protective under pad, folding walker, transport chair, and sales tax (S9999).. 
You say that the items were medically necessary. The Plan denied your request. The Plan says these items were 
purchased through a provider that is not enrolled in Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the protective under pad (T4537), 
folding walker (E0143), transport chair (E1038), and sales tax (S9999).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Leqvio. 
 You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the step therapy requirement is not 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has hyperlipidemia with 
vascular disease. She has not tried and failed the Plan's required drug, Praluent. The records do not show that 
the required drug would be contraindicated or less effective; therefore, Leqvio is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Leqvio.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a reverse total shoulder arthroplasty. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the submitted records do not contain 
documentation of a massive rotator cuff tear for this enrollee. The requested surgery is not reasonable or 
medically necessary for the enrollee 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a reverse total shoulder arthroplasty.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ondansetron. 
 
You asked the Plan to pre-approve Ondansetron. You say that this is for the prevention or treatment of nausea 
and vomiting associated with cancer chemotherapy. The Plan denied your request. The Plan says the 
medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. While the self-administered drugs requested here are covered by Medicare Part B in certain 
situations, the criteria have not been met. The documentation does not support that the oral anti-emetic drug 
administered with a particular chemotherapy treatment will be initiated within 2 hours of the administration of 
the chemotherapeutic agent and may be continued for a period not to exceed 48 hours from that time. 
Therefore, we decided that the Plan does not have to pre-approve Ondansetron.  
 
Benefits for Ondansetron may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for the paravertebral facet joint injections provided on April 26, 2023. 
 
You asked the Plan to pay for the paravertebral facet joint injection. You say that the enrollee updated their 
Coordination of Benefits and made the Plan their primary insurance for this date of service. The Plan denied 
your request. The Plan says that the enrollee's other insurance is primary to the 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 not met its obligation with regards to coordination of benefits. Specifically, the record does not 
show that the Plan has sent the bill directly to the primary insurer for payment, directed the provider to send the 
bill to the primary insurer or paid for the services and submitted a bill for reimbursement to the primary insurer. 
Therefore, we decided that the Plan has to pay for the paravertebral facet joint injections provided on April 26, 
2023.  
 
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: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure codes 92928, 93458, 92973, and 
99152. We decided that the Plan does not have to pay for the services described by procedure code 99153.  
 
You asked the Plan to pay for procedure code 99153 billed for date of service April 25, 2023. You say that 
medical records were submitted. The Plan says that there is no work component for this service. 
 
We decided that the Plan has to pay for the services described by procedure codes 92928, 93458, 92973, 
and 99152.  
 
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 92928, 93458, 92973, and 99152 
billed for date of service April 25, 2023.  
 
We also decided that the Plan does not have to pay for the services described by procedure code 99153. 
 
Medicare rules say that the OPPS recognizes that CPT code 99153 is a PE only code and that PE are not 
payable to the physician for services provided in the facility setting.  
 
The file shows that CPT code 99153 was billed with an outpatient hospital facility place of service code. There 
is no separate payment to the physician for CPT code 99153 when performed in the facility setting. 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 code 99153 billed for date of service 
April 25, 2023. 
 
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 codes 96365, 96366, 96521, J1817, and G0108 for date of 
service March 16, 2023. 
 
You asked the Plan to pay for codes 96365, 96366, 96521, J1817, and G0108. 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. Medicare rules also say that the evidence is 
adequate to conclude that outpatient intravenous (IV) insulin therapy (OIVIT) does not improve health 
outcomes in Medicare beneficiaries.  
 
We looked at the file and Medicare rules. Review of the file shows that codes 96365, 96366, 96521, and J1817 
are OIVIT services. These services are not covered. In addition, we find that CPT code G0108 is not supported 
in the medical record. Specifically, the submitted medical records do not indicate the time required for diabetes 
outpatient self-management training services, individual. Based on this information, we decided that Medicare 
rules for coverage of codes 96365, 96366, 96521, J1817, and G0108 have not been met. Therefore, we decided 
that the Plan does not have to pay for codes 96365, 96366, 96521, J1817, and G0108 for date of service March 
16, 2023.
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 the enrollee requires more intensive inpatient 
rehabilitation with daily physician management, continuous rehabilitation nursing, and intensive therapies to 
optimize mobility and strength while ensuring the restoration of functional status for a safe and sustainable 
discharge to their home. The Plan denied your request. The Plan says admission to an IRF is not medically 
necessary.  
 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 complexity of the enrollee's nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While the medical record supports a need for physical therapy and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary 
care can be provided in a different level of care. There is not a reasonable expectation that the enrollee 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for advance care planning services provided on May 02, 2023. 
 
You asked the Plan to pay for advance care planning services. You say that the enrollee was in a nursing home 
setting at the time services were rendered. 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 advance care planning 
services provided on May 02, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for computed tomography (CT) scan provided 
on April 17, 2023. 
 
You asked the Plan to waive the copayment for computed tomography (CT) scan. You say that you should not 
have a copayment, this test should be included in the lung cancer screening. 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 $175 
copayment for advanced radiology services. 
 
You have been asked to pay a $175 copayment for computed tomography (CT) scan. This item/service falls 
within the advanced radiology 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. However, since the allowed amount is less than the standard copayment, 
you only owe $137.36. Therefore, we decided that the Plan does not have to waive the copayment for 
computed tomography (CT) scan provided on April 17, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care from September 15, 2023, 
forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from September 15, 2023, forward. You say that 
the services at issue were medically necessary. The Plan denied your request. The Plan says the services at 
issue were not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric care from 
September 15, 2023, forward. Our reviewer says that the enrollee does not meet the criteria for treatment in an 
acute inpatient mental health treatment beyond the date in question of September 15, 2023, forward. Our 
physician reviewer found the enrollee did not require inpatient mental health treatment beyond September 15, 
2023, as she was not a danger to herself or others and did not have any delusions, auditory or visual 
hallucinations. It did not appear that active treatment was taking place beyond the date in question. It did not 
appear that the services for the dates in question were reasonably expected or medically necessary to improve 
the enrollees condition or for the purpose of diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric care from September 15, 2023, forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from September 15, 
2023, forward.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for vision care provided on May 23, 2023. 
 
You asked the Plan to waive the copayment for vision care. You say that you disagree with the copayment. 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 $35 
copayment for vision care. 
 
You have been asked to pay a $35 copayment for vision care. This item/service falls within the vision 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 vision care provided on May 23, 
2023.