Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dupixent pen (J3590). 
 
You asked the Plan to pre-approve Dupixent. 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. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve a Dupixent pen (J3590).   
Benefits for Dupixent 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care (99232) provided on June 16, 2022. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says the service is included in the global surgery period. 
 
The Plan must follow Medicare rules. Review of the file shows that the surgery procedure 10060 has a global 
value of 010 on the Centers for Medicare & Medicaid Services (CMS) National Physician Fee Schedule 
(NPFS) Relative Value (RVU) file. This is a minor procedure that has a global surgery period of 10 days. The 
initial evaluation (E/M code), 99232 is included when billed within the global surgery period of minor surgery 
procedure 10060, without an appropriate modifier. We looked at the file and Medicare rules. Based on this 
information, we decided that Medicare rules for coverage of the service have not been met. Therefore, we 
decided that the Plan does not have to pay for subsequent hospital care (99232) provided on June 16, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the physical therapy services. 
 
You asked the Plan to pre-approve the physical therapy services. The Plan denied your request. The Plan says 
the enrollee has back pain and a home exercise program to instruct the member on how to manage this pain. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 physical therapy services. Our 
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration 
of the enrollee's condition. Our physician reviewer found the additional therapy services are not an appropriate 
duration and frequency for treatment of the enrollees medical condition and therefore are not 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 the physical therapy services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the physical therapy services.
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 you are struggling and declining at the assisted living 
home and need rehab to regain strength and independence. The Plan denied your request. The Plan says the 
IRF services you are requesting do not meet the requirements for approval. 
 
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 your nursing, medical, and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the medical record 
supports a need for physical 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. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on February 6, 2023. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that at this time, there is no 
contractual agreement in place which indicates these tests are included in the dialysis rate. The Plan denied 
your request. The Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
February 6, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A4239 provided on February 2, 2023. 
 
You asked the Plan to pay for procedure code A4239. 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 providers must report services correctly. 
Providers must report services with the appropriate CPT code.  
We find that code A4239 has a status code of "P" under the Medicare Physicians Fee Schedule Database 
(MPFSDB) and no separate payment is made for this code under the fee schedule as payment is bundled into 
the payment for the services to which these codes are incident to. Therefore, we decided that the Plan does not 
have to pay for procedure code A4239 provided on February 2, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Clodan Kit. 
 
You asked the Plan to pre-approve the medication. You say that the enrollee needs this medication. 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. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve a Clodan Kit.   
Benefits for the medication 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve semi precision attachment abutment tooth #'s 22 and 27 
(D6052). 
 
You asked the Plan to pre-approve the semi precision attachment abutments. The Plan denied your request. The 
Plan says the requested services are related to implant or implant supported dentures and are not covered 
because services related to a major non-covered service are not covered. 
 Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers the semi 
precision attachment abutments when the services are medically necessary and reasonable.  
 
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 semi precision attachment 
abutments . Our reviewer says that the requested dental services are not medically necessary. Our physician 
reviewer found due to the lack of documentation of implant body placement in areas #22 and 27, the criteria for 
coverage for D6052, semi-precision attachment abutments have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the semi precision attachment abutments  have not been met. Therefore, we 
decided that the Plan does not have to pre-approve semi precision attachment abutment tooth #'s 22 and 27 
(D6052).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injections provided on January 09, 2023. 
 
You asked the Plan to pay for injections. You say that the services at issue were a medical necessity for the 
enrollee. 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 injections provided on 
January 09, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer. 
 
You asked the Plan to pre-approve Injectafer. You say that the requested Injectafer is medically necessary. The 
Plan denied your request. The Plan says the enrollee must try and fail Ferrlecit, Infed, or Venofer first. 
 
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 Injectafer. Our reviewer says that the 
Plan's step therapy criteria have not been met. Our physician reviewer found the Plan requires a trial of 
Ferrlecit, Infed, or Venofer first before they will approve the requested drug. In this case, the enrollee has not 
tried and failed the required drug(s). There is no documentation provided indicating that the Plans required 
drug(s) would likely be less effective and/or likely 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 Injectafer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Injectafer.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76140 billed for date of service December 1, 
2022. 
 
You asked the Plan to pay for procedure code 76140. You say that this should be paid for. The Plan denied 
your request. The Plan says the billed code is invalid for Medicare purposes.  
 
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 76140 has a Status Indicator of I on the Physician Fee Schedule. This means that procedure code 76140 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 76140 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 76140 billed for date of service December 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on October 10, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services were necessary and are supported in 
the medical record. The Plan denied your request. The Plan says you billed with an incorrect place of service 
on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on October 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 0003A billed for date of service May 28, 
2022.  
 You asked the Plan to pay for procedure code 0003A. You say that this is a covered service and this claim 
should be paid. 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 that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 0003A is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 0003A have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 0003A billed for date of service May 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder detect test (0012M) provided on November 
23, 2022. 
 
You asked the Plan to pay for the Cxbladder detect test. You say that this service was medically necessary. The 
Plan denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M for Cxbladder are non-
covered.   
 
We looked at the file and Medicare rules. The service at issue is non-covered. Based on this information, we 
decided that Medicare rules for coverage of the Cxbladder detect test have not been met. Therefore, we decided 
that the Plan does not have to pay for the Cxbladder detect test (0012M) provided on November 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 24, 2023. 
 
You asked the Plan to pay for the office visit. You say that the services were medically necessary. The Plan 
denied your request. 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 says that the Plan has 
also determined that these services are not urgent or emergent, nor were they approved in advance. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for an office visit provided on January 24, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on January 4, 2023. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that at this time, there is no 
contractual agreement in place which indicates that these tests should be included in the dialysis rate. The Plan 
denied your request. The Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on January 
4, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on July 28, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on July 28, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99602 and 99601 billed for date of service 
April 20, 2022. 
 
You asked the Plan to pay for procedure codes 99602 and 99601. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the billed codes are invalid for 
Medicare purposes.  
 
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 codes 99602 and 99601 have a Status Indicator of I on the Physician Fee Schedule. 
This means that procedure codes 99602 and 99601 are not valid for Medicare purposes. Based on this 
information, we decided that Medicare rules for coverage of procedure codes 99602 and 99601 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure codes 99602 and 99601 billed for 
date of service April 20, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal cord stimulator placement (95972, 77002, 
63650). 
 
You asked the Plan to pre-approve the spinal cord stimulator placement. You say that this device is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 The Plan follows Medicare rules. Medicare rules say that spinal cord stimulation may be covered for the relief 
of chronic intractable pain. Selection of patients for implantation of spinal cord stimulators is critical to success 
of this therapy. 
 
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 spinal cord stimulator placement. 
Our reviewer says that the requested treatment is not medically necessary. Our physician reviewer found the 
records do not support the spinal cord stimulator. The records do not show a psychiatric evaluation being 
performed prior to this treatment. 
 
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 spinal cord stimulator placement have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a spinal cord stimulator placement (95972, 77002, 63650).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93571 billed for date of service July 5, 2022. 
 
You asked the Plan to pay for procedure code 93571. You say that this service is supported in the medical 
record. The Plan denied your request. The Plan says this code is an add-on code which was not reported with a 
supported primary procedure. 
 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 
procedure code 93571 is an add-on code and has not been billed with an appropriate primary procedure code. 
Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 93571 billed for date of service July 5, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cala Trio nerve stimulator leads (K1019) provided on 
January 31, 2023. 
 You asked the Plan to pay for the Cala Trio nerve stimulator leads. You say that you would like proper 
payment of the billed charges. The Plan denied your request. The Plan says the denial of the Cala Trio nerve 
stimulator device was appropriate. 
 
The Plan follows Medicare rules. Medicare rules say that where electric nerve stimulation is employed to treat 
motor function disorders, no reimbursement may be made for the stimulator or for the services related to its 
implantation since this treatment cannot be considered reasonable and necessary. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the Cala Trio nerve stimulator leads. Our 
reviewer says that the Cala Trio nerve stimulator leads were not medically necessary. Our physician reviewer 
found the Cala Trio device was recommended to be used intermittently on demand for the enrollee's right hand 
for essential tremor. The enrollee is noted to have a slight action tremor in both hands with mild bradykinesia 
and a rare left hand rest tremor. Our reviewer found that an April 15, 2022, progress note states Right hand 
tremor is noted to be well controlled with Cala Trio. Our reviewer also found that the enrollee continues to 
have tremor in the left hand and face and the provider states will add Cala Trio to the left hand and try low dose 
primidone at night. 
 
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 Cala Trio nerve stimulator leads have not been met. Therefore, we decided 
that the Plan does not have to pay for the Cala Trio nerve stimulator leads (K1019) provided on January 31, 
2023.