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

 
We decided that the Plan does not have to pre-approve use of Panzyga. 
 You asked the Plan to pre-approve Panzyga. You say that this drug is recommended. The Plan denied your 
request. The Plan says the Plan requires a trial of Flebogamma DIF, Gammagard, Gammagard S/D, 
Gammaked, Gamunex-C, Hizentra, Octagam, Privigen, and Xembify before it will approve Panzyga. 
 
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 Panzyga. Our reviewer says that the 
enrollee does not meet criteria for a step therapy exception for Panzyga. Our physician reviewer found the 
enrollee has not tried and failed the Plan's preferred drugs of Flebogamma DIF, Gammagard, Gammagard S/D, 
Gammaked, Gamunex-C, Hizentra, Octagam, Privigen, and Xembify. The records do not show that these drugs 
would likely be less effective and/or have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Panzyga have not been met. Therefore, we decided that the Plan does not have 
to pre-approve use of Panzyga.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 standard power wheelchair, multiple power 
option, sling/solid seat/back, patient weight capacity up to and including 300 pounds (K0861), electronic 
connection (E2311), harness (E2313), expandable controller (E2377), and additional items and accessories 
(codes E1007, E1012, E2361, E2607, E2620, and K0108). 
 
You asked the Plan to pre-approve the durable medical equipment (DME). You say that the DME is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not have a medical need for multiple 
power options included with a K0861 group 3 power wheelchair. The Plan also says the electronic connection, 
harness, and expandable controller cannot be covered as it is not medically necessary to control the three 
requested power options through the joystick (drive interface). 
 
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 durable medical equipment (DME). 
Our physician reviewer found the enrollee does not have high risk for skin breakdown, use a catheter 
intermittently, have spasticity or require an alternative means of managing power drive. Criteria for power tilt 
and recline not 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 the durable medical equipment (DME) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a group 3 standard power wheelchair, multiple power 
option, sling/solid seat/back, patient weight capacity up to and including 300 pounds (K0861), electronic 
connection (E2311), harness (E2313), expandable controller (E2377), and additional items and accessories 
(codes E1007, E1012, E2361, E2607, E2620, and K0108).
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve the LinQ procedure (0775T). 
 
You asked the Plan to pre-approve the LinQ procedure. You say that the enrollee meets the proper medical 
criteria for being an appropriate surgical candidate for the requested procedure. The Plan denied your request. 
The Plan says that the LinQ device is still being studied to see if the treatment is reasonable and necessary. The 
Plan says that there is lack of evidence to support the LinQ device over traditional treatment of sacroiliac (SI) 
joint pain with other methods of percutaneous minimally invasive fusion/stabilization of the sacroiliac joint.  
 
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 LinQ procedure. Our reviewer says 
that the requested services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has chronic low back pain and sacroiliitis. Imaging shows arthropathy at the 
sacroiliac (SI) joint. The service represented by code 0775T is being recognized as an established procedure in 
3 months. This procedure is no longer considered experimental and would be medically reasonable and 
necessary in this case. 
 
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 LinQ procedure have been met. Therefore, we decided that the Plan has to 
pre-approve the LinQ procedure (0775T).  
 
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: Favorable

 
We decided that the Plan has to pre-approve Ozurdex. 
 
You asked the Plan to pre-approve Ozurdex. You say that the services are necessary. The Plan denied your 
request. The Plan says that based on the documentation provided, coverage criteria has not been met. 
 
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 Ozurdex. Our reviewer says that the 
services are medically necessary. Our physician reviewer found given that ozurdex is FDA approved for 
diabetic associated macular edema and the documentation support this diagnosis, the medication is indicated, 
medically reasonable and FDA 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 Ozurdex have been met. Therefore, we decided that the Plan has to pre-approve 
Ozurdex.  
 
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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Hyalgan (J7321). 
 You asked the Plan to pre-approve the medication. You say that Hyalgan is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says step-therapy rules for coverage of Hyalgan have not been 
met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the medication. Our physician reviewer 
found the documentation does not outline contraindications or reasons these medications were not considered 
or that the Plan's additional required drugs would likely be less effective and/or likely have adverse effects for 
the enrollee. Without the support of the documentation, Hyalgan is not approved as step 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 the medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve treatment with Hyalgan (J7321).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81456 billed for date of service March 10, 
2023.  
 
You asked the Plan to pay for procedure code 81456. You say that the NCCI has agreed to change the NCCI 
indicator to 1, which would allow payment for these two codes together. The Plan denied your request. The 
Plan says payment for code 81456 is bundled into payment for code 81455. 
 
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, we have confirmed that code 81456 is a column II code to column I code 81455 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Please note that the NCCI 
indicator change that you reference was not officially implemented until October 1, 2023. This date is well 
after your date of appeal. As a result, the Plan cannot be obligated to bypass this edit. You have the right to 
submit the claim again for additional consideration based on the rule change. Therefore, we decided that the 
Plan does not have to pay for procedure code 81456 billed for date of service March 10, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous image-guided lumbar decompression 
(PILD or the MILD procedure). 
 
You asked the Plan to pre-approve MILD procedure. You say that the enrollee is an excellent candidate for this 
procedure. The Plan denied your request. The Plan says the enrollee does not meet criteria for this procedure. 
 
The Plan follows Medicare rules. Medicare rules state that the MILD procedure may be covered through an 
approved CED study for which the enrollee meets criteria. 
 
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 MILD procedure. Our reviewer says 
that the enrollee does not meet criteria for this procedure. Our physician reviewer found the provided records 
document that the enrollee has had a lumbar laminectomy and the records do not clarify that this procedure was 
not performed during the 12 months prior to the planned MILD procedure. 
 
We looked at this physician's review, the file, and Medicare rules. You are requesting that the enrollee 
participate in NCT03072927. While this is an approved CED study that is currently recruiting participants, our 
physician reviewer found that the enrollee may meet the exclusion criterion prohibiting participation. Based on 
this information, we decided that Medicare rules for coverage of MILD procedure have not been met. 
Therefore, we decided that the Plan does not have to pre-approve percutaneous image-guided lumbar 
decompression (PILD or the MILD procedure).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc (J7325). 
 
You asked the Plan to pre-approve the medication. You say that Synvisc is a necessity for your care. The Plan 
denied your request. The Plan says step-therapy rules for coverage of Synvisc have not been met.  
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the medication. Our physician reviewer 
found the record indicates that you have osteoarthritis of the knees. The requested medication is a new 
start. The provided records do not indicate that you have tried and failed the Plan's preferred step one 
alternative. The record does not indicate that you have a contraindication to or would have an adverse effect 
from the Plan's preferred step one alternative. The elements of the coverage criteria 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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Synvisc (J7325).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for group psychotherapy provided on April 4, 2023. 
 
You asked the Plan to pay for the group psychotherapy. The Plan denied your request. The Plan says this 
provider is listed as being a student in an organized health care education/training program and therefore does 
not meet the Medicare and the Plan criteria.  
 
The Plan must follow Medicare rules. Medicare rules say that no provider or supplier shall receive payment for 
services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare program. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the group psychotherapy have not been met. Therefore, we decided that the Plan does not have to 
pay for group psychotherapy provided on April 4, 2023.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pay for outpatient therapy services provided on June 1, 2022, to June 16, 2022. 
 
You asked the Plan to pay for outpatient therapy services. You say that this should be covered. The Plan denied 
your request. The Plan says that this was not billed with a certified National Provider Identifier (NPI). 
 
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. The Plan states that this was denied based on the billed NPI but has not provided 
a reason that the NPI is invalid or uncertified. The billed NPI is listed as participating in Medicare. Therefore, 
we decided that the Plan has to pay for outpatient therapy services provided on June 1, 2022, to June 16, 2022.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81456 billed for date of service June 2, 2023.  
 
You asked the Plan to pay for procedure code 81456. You say that the NCCI has agreed to change the NCCI 
indicator to 1, which would allow payment for these two codes together. The Plan denied your request. The 
Plan says payment for code 81456 is bundled into payment for code 81455. 
 
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, we have confirmed that code 81456 
is a column II code to column I code 81455 with a modifier indicator of 0. The column II code is therefore not payable. Based on the claim submitted, Medicare billing criteria have not been met. Please note that the NCCI 
indicator change that you reference was not officially implemented until October 1, 2023. This date is well 
after your date of appeal. As a result, the Plan cannot be obligated to bypass this edit. You have the right to 
submit the claim again for additional consideration based on the rule change. Therefore, we decided that the 
Plan does not have to pay for procedure code 81456 billed for date of service June 2, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on December 21, 
2022. 
 
You asked the Plan to waive the copayment for an office visit. You say that this was a wellness visit. 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 in-network specialist visits. 
 
You have been asked to pay a $35 copayment for an office visit. This item/service falls within the in-network 
specialist visits 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 an office visit provided on 
December 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81456 billed for date of service January 2, 
2023.  
 
You asked the Plan to pay for procedure code 81456. You say that the NCCI has agreed to change the NCCI 
indicator to 1, which would allow payment for these two codes together. The Plan denied your request. The 
Plan says payment for code 81456 is bundled into payment for code 81455. 
 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, we have confirmed that code 81456 
is a column II code to column I code 81455 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Please note that the NCCI 
indicator change that you reference was not officially implemented until October 1, 2023. This date is well 
after your date of appeal. As a result, the Plan cannot be obligated to bypass this edit. You have the right to 
submit the claim again for additional consideration based on the rule change. Therefore, we decided that the 
Plan does not have to pay for procedure code 81456 billed for date of service January 2, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on June 21, 2023 to June 28, 
2023. 
 
You asked the Plan to pay for the home health services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that home health agencies must submit home health 
Prospective Payment System (PPS) claims with a type of bill with the 4th digit of 9. 
 
We looked at the file and Medicare rules. The claim was submitted with a type of bill of 0323. Based on this 
information, we decided that Medicare rules for coverage of the home health services have not been met. Therefore, we decided that the Plan does not have to pay for home health services provided on June 21, 2023 to 
June 28, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services billed with the Patient 
Driven Payment Model (PDM) score of KAFE1 for dates of service August 29, 2022, to September 26, 2022. 
 
You asked the Plan to pay for the SNF services at the KAFE1 PDPM score. You say that you have provided 
medical records to support payment at the rate billed. The Plan denied your request. The Plan says you did not 
provide records for the required 5-day assessment, so the default PDPM score of ZZZZZ was paid. 
 The Plan must follow Medicare rules. Medicare rules say that SNFs are required to provide and document a 5-
day assessment within the medical record.  If no such assessment is documented or performed, the SNF claim 
is processed based on a PDPM default score of ZZZZZ. 
 
In this case, you did not provide evidence of the required 5-day assessment.  That is why the Plan paid your 
claim based on the PDPM default score of ZZZZZ. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the SNF services at the KAFE1 PDPM score. have not been met. Therefore, we decided that the 
Plan does not have to pay for skilled nursing facility (SNF) services billed with the Patient Driven Payment 
Model (PDM) score of KAFE1 for dates of service August 29, 2022, to September 26, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for physical therapy on March 22, 2022, to 
February 17, 2023.  
 
You asked the Plan to waive the copayments for physical therapy. You say that you were informed there would 
only be $35 copayment collected at each visit. 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 Medicare-covered physical therapy in-person visits. You must pay a $55 copayment for out-of-
network Medicare-covered physical therapy visits. You must pay a $50 copayment for out-of-network 
Medicare-covered Physical Therapy in-person visits. Covered services include physical therapy (in-person or 
virtual), occupational therapy, and speech language therapy in-person visits. For the year 2022 there were 
twenty-one visits with a $55 copayment. 21 x $55 = $1,155. For date of service 05/05/2022, there was a $35 
copayment. For the year 2023 there were five visits with a $50 copayment. 5 x $50 = $250. For all dates of 
service, it's $1,155 + $35 + $250 =$1,440. A payment was made in the amount of $10 for the service. $1,440 - 
$10 = $1,430. Therefore, results in the total cost sharing amount of $1,430. 
 
You have been asked to pay a $1,430 cost share for physical therapy. This item/service falls within the 
outpatient rehabilitation 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 copayments for 
physical therapy on March 22, 2022, to February 17, 2023.