Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a magnetic resonance imaging (MRI) of lower extremity joint. 
 
You asked the Plan to pre-approve the MRI. You say that the enrollee is in a lot of pain, unable to walk and has 
a history of rheumatoid arthritis. The Plan denied your request. The Plan says that the records received do not 
show six weeks of provider directed treatment. 
 
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 the MRI. Our reviewer says that the 
MRI is medically necessary. Our physician reviewer found the enrollee has rheumatoid arthritis and takes daily 
prednisone. These facts constitute a red flag. Request for an MRI of the left hip should be approved. 
 
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 MRI have been met. Therefore, we decided that the Plan has to pre-approve 
a magnetic resonance imaging (MRI) of lower extremity joint.  
 
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 physicians services provided on August 17, 2023. 
 
You asked the Plan to pay for physicians services. You say that the 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 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 physicians services 
provided on August 17, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility provided on August 11, 2023. 
 
You asked the Plan to pay for skilled nursing facility. You say that it is the responsibility of the facility to 
obtain prior authorization. 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 skilled nursing facility 
provided on August 11, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility provided on August 04, 2023. 
 
You asked the Plan to pay for skilled nursing facility. You say that you are requesting a 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 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 skilled nursing facility 
provided on August 04, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xgeva (J0897). 
 You asked the Plan to pre-approve Xgeva. You say that this is medically necessary for the enrollee's condition. 
The Plan denied your request. The Plan says the enrollee has not tried and failed the preferred drugs, 
intravenous pamidronate or zoledronic acid. 
 
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 Xgeva. Our reviewer says that the step 
therapy criteria have not been met. Our physician reviewer found the provided documentation does not indicate 
that the enrollee has trialed and failed the preferred drugs, an intravenous pamidronate or zoledronic acid. The 
reviewer also found that the documentation does not support that intravenous pamidronate or zoledronic acid 
would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. 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 Xgeva have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Xgeva (J0897).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve injection(s), anesthetic agent(s) and/or steroid; genicular 
nerve branches, including imaging guidance (64454). 
 
You asked the Plan to pre-approve injection(s), anesthetic agent(s) and/or steroid; genicular nerve branches, 
including imaging guidance. You say that this is medically necessary. The Plan denied your request. The Plan 
says this is not medically necessary because based on the medical literature this procedure is considered 
experimental or investigational and has not been proven to be beneficial for the enrollee's condition. 
 
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 injection(s), anesthetic agent(s) and/or 
steroid; genicular nerve branches, including imaging guidance. Our reviewer says that the requested 
items/services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found genicular nerve injection and block is experimental for knee pain. More research is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of injection(s), anesthetic agent(s) and/or steroid; genicular nerve branches, 
including imaging guidance have not been met. Therefore, we decided that the Plan does not have to pre-
approve injection(s), anesthetic agent(s) and/or steroid; genicular nerve branches, including imaging guidance 
(64454).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the over-the-counter (OTC) COVID-19 test 
purchased on July 27, 2023. 
 
You asked the Plan to reimburse you for the OTC COVID-19 test. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says over-the-counter (OTC) 
COVID-19 tests are not covered by Medicare after May 11, 2023. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC COVID-19 tests after 
May 11, 2023. Therefore, we decided that the Plan does not have to reimburse you for the over-the-counter 
(OTC) COVID-19 test purchased on July 27, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panel testing (87798, 87511, and 87481) provided on 
March 1, 2023. 
 
You asked the Plan to pay for procedure codes 87798, 87511, and 87481. You say that you would like the Plan 
to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered 
as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically necessary and used to perform the test.  
 
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid 
probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for the panel testing (87798, 87511, and 87481) provided on March 1, 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 the enrollee does not meet the requirements for a 
SNF admission. The Plan denied your request. The Plan says the enrollee needs SNF services. 
 
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 that the enrollee does not meet the severity of illness or intensity of service criteria 
for an inpatient basis in a skilled nursing facility. The enrollee does not require skilled nursing services on a 
daily basis. The medical records show identifiable skilled therapy needs; however, these services are not 
required daily on an inpatient basis in a SNF.  
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy provided on September 26, 2023. 
 
You asked the Plan to pay for physical therapy. You say that you are asking for 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 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 physical therapy 
provided on September 26, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cervical traction equipment (E0849), provided on April 
30, 2023. 
 
You asked the Plan to pay for the cervical traction equipment. You say that the item is medically necessary. 
The Plan denied your request. The Plan says there is no documentation indicating a diagnosis of TMJ 
dysfunction, or that enrollee has received treatment for this condition. There is no evidence of a distortion of 
the lower jaw or neck anatomy (e.g. radical neck dissection) such that a chin halter is unable to be utilized. The 
documentation does not indicate that the appropriate use of the device has been demonstrated. There is no 
evidence that the enrollee can tolerate the device, or that the enrollee requires greater than 20 pounds of 
cervical traction in the home setting. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. There is no indication this item was discussed, needed or ordered by the physician in the clinical 
records submitted.. The record shows that the Plan made several attempts to obtain the necessary 
documentation without success. Therefore, we decided that the Plan does not have to pay for the cervical 
traction equipment (E0849), provided on April 30, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87798 and 87634 for date of service July 
20, 2023. 
 
You asked the Plan to pay for procedure codes 87798 and 87634. 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 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 CPT Code Manual definition of code 87798 is infectious agent detection by nucleic acid (DNA 
or RNA), not otherwise specified; amplified probe technique, each organism. 
 
We find that CPT code 87798 is not supported in the medical record. Specifically, this service represents a not 
otherwise specified code. However, a complete description of the not otherwise specified code was not 
included. The order/lab requisition/claim must include what laboratory test was ordered/requested for this code 
in order to validate the code billed. 
 
The MUE for CPT code 87634 is 1. The MAI value for this code is 3. You billed 2 units of this code, 
exceeding the MUE. You did not provide all the required evidence showing that the excess units were actually 
provided, were correctly coded, and were medically necessary. 
 
Based on this information, we decided that Medicare rules for coverage of procedure codes 87798 and 87634 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 87798 and 
87634 for date of service July 20, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G7 continuous glucose monitor (CGM).  
You asked the Plan to pre-approve a Dexcom G7 CGM. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a Dexcom G7 CGM. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found provided records in this case do not 
document the enrollee is insulin treated and does not document a history of problematic hypoglycemia. 
 
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 Dexcom G7 CGM have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Dexcom G7 continuous glucose monitor (CGM).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repair of blepharoptosis to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve repair of blepharoptosis. You say that the services should be covered. The 
Plan denied your request. The Plan says this is available in-network. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
repair of blepharoptosis to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Qutenza (J7336). 
 
You asked the Plan to pre-approve Qutenza. You say that this is not being pharmacy dispensed. The Plan 
denied your request. The Plan says this is not being prescribed for a medically accepted indication. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Qutenza. Our reviewer says that the 
requested use of Qutenza is not medically necessary. Our physician reviewer found the requested use of 
Qutenza is not FDA-approved for the enrollees diagnosis. Its use is not supported by one of the major drug 
compendia or by clinical research that appears in a CMS-approved medical journal (see appendix for list of 
CMS-approved journals). Therefore, the reviewer found that the requested use of Qutenza 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 Qutenza have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Qutenza (J7336).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the fluid circulating cold pad with pump (E0218) 
provided on May 11, 2023, through Mau 30, 2023. 
 
You asked the Plan to pre-approve the fluid circulating cold pad with pump=. You say that the item was 
medically necessary. The Plan denied your request. The Plan says the item was not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a fluid circulating cold pad with pump (E0218) 
will be denied as not reasonable and necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the fluid circulating cold pad with pump= have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the fluid circulating cold pad with pump (E0218) provided on May 11, 2023, 
through Mau 30, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ER services provided on May 29, 2022. 
 
You asked the Plan to pay for ER services. You say that this should be covered. The Plan denied your request. 
The Plan says to receive payment, the claim should have been filed no later 12 months after the date of service. 
This means that more than one calendar year from the date of service had passed before a claim was filed.  
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for ER services was not filed until June 8, 2023. This means that more than one 
calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan 
does not have to pay for ER services provided on May 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bone replacement graft for ridge preservation (D7953), and 
biologic materials to aid in soft and osseous tissue regeneration (D4265) provided on September 7, 2023 
 
You asked the Plan to pay for D7953 and D4265. You say that you thought that the extraction would at least be 
covered. The Plan denied your request. The Plan says the rendered dental services have been processed 
correctly. 
 
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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for bone 
replacement graft for ridge preservation (D7953), and biologic materials to aid in soft and osseous tissue 
regeneration (D4265) provided on September 7, 2023
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular artery embolization. 
 
You asked the Plan to pre-approve genicular artery embolization. You say that this is medically necessary for 
the enrollee. The Plan denied your request. The Plan says this is experimental for the enrollee's condition. 
 
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 artery embolization. Our 
reviewer says that the requested genicular artery embolization is not considered medically reasonable and 
necessary in this case. Our physician reviewer found this is considered experimental/ investigational 
therapy.  Therefore, the reviewer found that the requested genicular artery embolization is not 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 genicular artery embolization have not been met. Therefore, we decided that the 
Plan does not have to pre-approve genicular artery embolization.