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

 
We decided that the Plan has to pre-approve a membrane graft or membrane wrap. 
 
You asked the Plan to pre-approve the membrane graft or membrane wrap. You say that you are appealing with 
supporting records. The Plan denied your request. The Plan says that the request is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 the membrane graft or membrane wrap. 
Our reviewer says that the requested items/services are considered medically reasonable and necessary in this 
case. Our physician reviewer found that this enrollee has been suffering with an open ulceration to the posterior 
aspect of the left heel for a couple of weeks prior to August 2, 2023. Since that time the wound has only 
reduced by a small amount and the wound is devitalized tissue and 75% is granulation tissue. The enrollee is 
noted to be suffering with a non-healing wound to the posterior aspect of the left heel. The wound has been 
open for greater than three months with little resolution. The enrollee has failed conservative treatments for 
greater than three months. Membrane grafts and wraps are widely used as biologic skin substitutes and ulcer 
dressings to improve the ability of the wound to granulate and heel.  
 
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 membrane graft or membrane wrap have been met. Therefore, we decided 
that the Plan has to pre-approve a membrane graft or membrane wrap.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Epoetin.  
 
You asked the Plan to pre-approve Epoetin. You say that this drug is medically necessary for the enrollee's 
condition. The Plan denied your request. The Plan says the drug is not medically necessary. 
 
The rules say that Medicare may cover a drug or biological if it is safe and effective and otherwise reasonable 
and necessary. The local coverage article enumerates additional conditions and limitations of coverage for the 
requested service. 
 
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 Epoetin. Our reviewer says that the 
drug is not medically necessary. Our physician reviewer found medical records do not support that this drug is 
medically reasonable and 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 Epoetin have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Epoetin.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the steroid injection (64455) provided on 
October 03, 2023. 
 
You asked the Plan to waive the copayment for the steroid injection (64455). You say that this injection was 
not given in an operating room. 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 $350 
copayment for outpatient surgery in an outpatient hospital facility. 
 
You have been asked to pay a $350 copayment for the steroid injection (64455). This item/service falls within 
the outpatient surgery in an outpatient hospital facility 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. According to Medicare, a steroid injection (64455) is 
considered a surgical procedure. Therefore, we decided that the Plan does not have to waive the copayment for 
the steroid injection (64455) provided on October 03, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the out-of-network diagnostic services 
provided on July 24, 2023. 
 
You asked the Plan to waive the coinsurance for the out-of-network diagnostic 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 30% 
coinsurance for Outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay 30% coinsurance for the out-of-network diagnostic services. This item/service 
falls within the Outpatient diagnostic tests and therapeutic services and supplies 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 coinsurance for the out-of-network diagnostic services provided on July 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for yaluronan or derivative, synvisc or synvisc 
one, for intraarticular injection (J7325) provided on September 06, 2023. 
 
You asked the Plan to waive the coinsurance for yaluronan or derivative, synvisc or synvisc one, for 
intraarticular injection (J7325). You say that the cost share is worng. 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 20% 
coinsurance for Medicare Part B prescription srufs. 
 
You have been asked to pay 20% coinsurance for yaluronan or derivative, synvisc or synvisc one, for 
intraarticular injection (J7325). This item/service falls within the Medicare Part B prescription srufs 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 coinsurance for yaluronan or derivative, synvisc or synvisc 
one, for intraarticular injection (J7325) provided on September 06, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A4221, A4223, A4305 billed for date of 
service June 18, 2023, to July 19, 2023. 
 
You asked the Plan to pay for procedure code A4221, A4223, A4305. You say that you require reimbursement 
for the unpaid charges that are indicated on this claim that include necessary supplies and service charges 
applicable to the medication that was administered to the enrollee. The Plan denied your request. The Plan says 
procedure codes A4221, A4223, A4305 are not 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 A4221and A4223 have a status indicator of X on the Physician Fee Schedule. This 
means that procedure code A4221 and A4223 have a statutory exclusion and is not in the statutory definition of 
physician services for fee schedule payment purposes. We also find that procedure code A4305 has a status 
indicator of P on the Physician Fee Schedule. This means that the code is a bundled/excluded code. No separate 
payment is made for them under the fee schedule. Based on this information, we decided that Medicare rules 
for coverage of procedure code A4221, A4223, A4305 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code A4221, A4223, A4305 billed for date of service June 18, 2023, to July 
19, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a glucose monitor sensors provided on September 19, 2023. 
 
You asked the Plan to pay for glucose monitor sensors. You say that this should be covered. The Plan denied 
your request. The Plan says items categorized with code A9276 are not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that glucose monitor products categorized as code 
A9276 are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of glucose monitor sensors have not been met. Therefore, we decided that the Plan does not have to 
pay for a glucose monitor sensors provided on September 19, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of an ILR. 
 You asked the Plan to pre-approve the requested ILR procedure. You say that this is medically necessary. The 
Plan denied your request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say ILR placement may be considered medically 
necessary when it is needed to evaluate syncope that is thought to be cardiac-related but occurs too infrequently 
to be detected by traditional external monitors.  
 
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 requested ILR procedure. Our 
reviewer says that the requested ILR procedure is not medically reasonable and necessary based on NCD 
criteria. Our physician reviewer found you are easily fatigued but deny palpitations. The electrocardiogram 
shows normal sinus bradycardia and your dobutamine stress echocardiogram was negative for ischemia. The 
records document no syncope or near-syncope and overall are inadequate to document necessity of the 
insertion of the loop recorder. 
 
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 requested ILR procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve placement of an ILR.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the arthrocentesis procedure provided on June 20, 2023. 
 
You asked the Plan to pay for the arthrocentesis procedure. You say that you are requesting reconsideration of 
the denied claim. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The 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 arthrocentesis procedure provided on June 20, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on October 23, 2023. 
 
You asked the Plan to pay for lab services. You say that these services were 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 services provided on October 23, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablation procedure. 
 
You asked the Plan to pre-approve genicular nerve radiofrequency ablation procedure. You say that you are 
requesting reconsideration for the denied claim. The Plan denied your request. The Plan says medical studies 
haven't proven this requested service is helpful for the treatment of your health problem. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve genicular nerve radiofrequency ablation 
procedure. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found genicular nerve blocks and genicular nerve ablation are 
considered investigational and not medically necessary for the treatment of chronic knee pain, including, but 
not limited to any of the following: degenerative joint disease; osteoarthritis of the knee; as a treatment prior to knee replacement; as a treatment following knee replacement; or as a treatment for individuals who are not 
candidates for knee replacement surgery.   
 
The review has determined that the requested radiofrequency ablation of the genicular nerve for chronic left 
knee pain is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genicular nerve radiofrequency ablation procedure have not been met. 
Therefore, we decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablation 
procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0248 billed for date of service July 11, 
2023. 
 
You asked the Plan to pay for G0248. You say that G0248 should be paid as billed because the records support 
medical necessity. The Plan denied your request. The Plan says G0248 is denied because the records do not 
include full documentation of this service. 
 
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 G0248 is demonstration, prior to initiation of home 
international normalized ratio (INR) monitoring, for patient with either mechanical heart valve(s), chronic atrial 
fibrillation, or venous thromboembolism who meets Medicare coverage criteria, under the direction of a 
physician; includes: face-to-face demonstration of use and care of the INR monitor, obtaining at least one blood 
sample, provision of instructions for reporting home INR test results, and documentation of patient's ability to perform testing and report results. 
 
We find that CPT code G0248 is not supported in the medical record. Specifically, we confirmed that the 
records do not contain documentation of face-to-face demonstration of the use and care of the INR monitor, 
provision of instructions for reporting home INR test results, or documentation of the enrollee's ability to 
perform testing and report results. These facets of the code definition are required for reporting G0248. Based 
on this information, we decided that Medicare rules for coverage of G0248 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code G0248 billed for date of service July 11, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a raised toilet seat. 
 
You asked the Plan to pre-approve a raised toilet seat. You say that the item is medically necessary. The Plan 
denied your request. The Plan says this item is a convenience item, hygienic in nature, and not primarily 
medical in nature. 
 
The Plan covers all items that Medicare covers. Medicare rules state that raised toilet seats are not covered 
because they are not primarily medical in nature.  
 
While a raised toilet seat may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a raised toilet seat.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A0425 billed for date of service August 18, 
2023.  
 
You asked the Plan to pay for procedure code A0425. You say that the patient was transported from a rural 
critical access hospital to the closest facility that could provide care. 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 when an MUE has an MAI of 1, units in excess of the 
MUE are only payable when reported on a separate claim line with appropriate use of a modifier.  
 
In this case, the MUE for CPT code A0425 is 250. The MAI value for this code is 1. You billed 261 units of 
this code, exceeding the MUE. The units in excess of the MUE were not reported on a separate claim line with 
an appropriate modifier as required. Based on this information, we decided that Medicare rules for coverage of 
procedure code A0425 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code A0425 billed for date of service August 18, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary. The Plan denied 
your request. The Plan says the criteria for SNF care has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require skilled nursing services to provide medically necessary 
and reasonable treatment. The enrollee does require therapy services, however there are no records that show 
you need daily inpatient skilled therapy services. The enrollee does not meet severity of illness or intensity of 
service criteria for an inpatient basis in a skilled nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve NovoSorb SynPath skin substitute graft. 
 
You asked the Plan to pre-approve NovoSorb SynPath. 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 NovoSorb SynPath. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found under the plan policy, wounds must be present and unresponsive to conservative 
therapy for at least 30 days. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of NovoSorb SynPath have not been met. Therefore, we decided that the Plan does 
not have to pre-approve NovoSorb SynPath skin substitute graft.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supply allowance for a continuous glucose monitor 
(CGM) provided on August 2, 2023. 
 
You asked the Plan to pay for the supply allowance for a CGM. You say that you have submitted proof of 
delivery along with other supporting documentation, but the claim keeps denying for missing this information. 
The Plan denied your request. The Plan says the provider is not a plan contract provider and is not enrolled in 
Medicare as a durable medical equipment supplier. 
 
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 supply allowance for a continuous 
glucose monitor (CGM) provided on August 2, 2023.