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

 
We decided that the Plan does not have to pay for the Synvisc-One (J7325) provided on June 21, 2022. 
 
You asked the Plan to pay for the Synvisc-One. You say that the provider says the services were deemed 
medically necessary. The Plan denied your request. The Plan says this procedure is not medically necessary for 
the diagnosis and treatment of the member's illness or injury. 
 
 
 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 pay for the Synvisc-One. Our reviewer says that 
Synvisc-One was not medically reasonable and necessary for the enrollee. Our physician reviewer found the 
record indicates that the enrollee has a diagnosis of osteoarthritis of the knee. The record indicates that the 
requested device is to be used with intra-articular steroids. Our reviewer found that the FDA has not stated that 
the requested drug is indicated for the enrollee's condition with concomitant use with other intra-articular 
injectables. The Medicare approved drug compendia do not contain a supportive citation for the use of the 
requested device as prescribed in the enrollee's clinical situation. Our physician reviewer also found that the 
elements of the coverage criteria are not satisfied, and 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 Synvisc-One have not been met. Therefore, we decided that the Plan does 
not have to pay for the Synvisc-One (J7325) provided on June 21, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 95886 rendered on October 21, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that the documentation indicates that this service was performed on the right and left lower 
extremity. 
 
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 95886 is "Needle electromyography, each extremity, with related paraspinal areas, when performed, done 
with nerve conduction, amplitude and latency/velocity study; complete, five or more muscles studied, 
innervated by three or more nerves or four or more spinal levels (List separately in addition to code for primary 
procedure)." 
 
We asked our coder 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 services. Our reviewer says that the services at issue in 
this case were supported by the medical records. Our reviewer found that the medical record supports one unit 
of 95886, which according to the claim, is what the provider billed. According to the Medicare Fee Schedule, 
the bilateral indicator for CPT code 95886 is 3, which means that a payment adjustment for a bilateral 
procedure does not apply. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for 
procedure code 95886 rendered on October 21, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99220 and 99497 rendered on September 6, 
2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services 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. 
 
In this case, the CPT Code Manual definition of the denied codes is: 
 
CPT 99220: 
 
Initial observation care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high 
complexity. Counseling and/or coordination of care with other physicians, other qualified health care 
professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or 
family's needs. Usually, the problem(s) requiring admission to outpatient hospital "observation status" are of 
high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor or unit 
 
CPT 99497: 
 
Advance care planning including the explanation and discussion of advance directives such as standard forms 
(with completion of such forms, when performed), by the physician or other qualified health care professional; 
first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate 
 
We asked our coder 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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that CPT 99497 is not supported. The 
part of record that states advanced care planning was performed includes services that are part of the evaluation 
and management service, such as discussing the diagnosis and treatment goals. This does not support 99497 as 
a separately identifiable service. In terms of CPT 99220, it is not supported. The documentation does not 
support medical decision making of high complexity. The medical decision making included continuing the 
enrollee's treatment plan for chronic conditions and treating the acute complaint with IV fluids and medication 
management. This supports medical decision making of moderate complexity. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes 99220 and 99497 rendered on September 6, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the enrollee has tried a CPAP and was 
placed on a Bipap during hospitalization in July 2020, but due to high PCO2 level of 76 and hypoxemia patient 
was prescribed NIV therapy. NIV therapy is medically necessary due to patients' inability to expand and retract 
lungs fully without additional supportive therapy and decrease the chance of any continued unplanned medical 
encounters. The Plan denied your request. The Plan says the records do not show the enrollee has failed 
treatment with CPAP or BIPAP or that the requested NIV will not be used exclusively in CPAP or bi-level 
PAP mode. The request is not medically necessary. 
 
 The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has a listed diagnosis of 
COPD and has severe obesity. The enrollee was hospitalized in July 2020 with pneumonia. ABG was 
consistent with acute on chronic hypercarbic respiratory failure. There was apparently no history of COPD at 
that time. There are no pulmonary function tests to confirm airways obstruction or assess severity. There is no 
diagnosis of thoracic restrictive disease or neuromuscular disease.  There is no ABG done while stable to 
confirm chronic CO2 retention. If that is present, and the enrollee has severe COPD, he may benefit from 
BiPAP with AVAPS during sleep. Medicare does not cover a home ventilator when used at settings that can be 
provided with BiPAP. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Feraheme. 
 You asked the Plan to pre-approve Feraheme. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the Plan requires a trial of Venofer before they will approve Feraheme. 
 
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 Feraheme. Our reviewer says that you 
do not meet the criteria for a step therapy exception for Feraheme. Our physician reviewer found the record 
does not show that you have tried and failed the Plan's preferred drug of Venofer. The record does not show 
that this drug would likely be less effective and/or have adverse effects for you. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Feraheme have not been met. Therefore, we decided that the Plan does not have 
to pre-approve use of Feraheme.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the total knee arthroplasty, right (Current Procedural 
Terminology 27447). 
 
You asked the Plan to pre-approve the total knee arthroplasty. You say that the services are medically 
necessary. The Plan denied your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the total knee arthroplasty. Our 
reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our 
physician reviewer found detailed documentation regarding a trial and failure of recent, reasonable, 
comprehensive, less invasive conservative care measures is not evident. The documentation does not support 
any current medications or physical therapy or a recent history of trial and failure of medication or therapy. There are limited large-scale, long-term references showing the safety and efficacy of the requested surgery in 
this clinical setting. No compelling rationale is presented or extenuating circumstances noted to support the 
medical necessity of this request as an exception. 
 
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 total knee arthroplasty have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the total knee arthroplasty, right (Current Procedural Terminology 27447).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that you are appealing the denial for SNF because you 
do not feel safe going home. The Plan denied your request. The Plan says that your request does not meet the 
criteria for medical necessity. 
 
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 You do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) 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 skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that your condition is chronic on an ongoing 
basis, this is not temporary. You have a condition co2 build up in his blood, can slip in coma and die. the 
ventilator only thing that helps him. The Plan denied your request. The Plan says the records do not show you 
have failed treatment with CPAP or BIPAP or that the requested NIV will not be used exclusively in CPAP or 
bi-level PAP mode. The request is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 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 home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found you have a listed diagnosis of COPD 
and have severe obesity. You have reportedly been hospitalized in the past for hypercarbic respiratory failure, 
but no details are given. There are no pulmonary function tests to confirm airways obstruction or assess 
severity. You currently have a home ventilator. Device data covering April 7, to May 2, 2023, showed an 
average use of 8.3 hours/day. There is no ABG done while stable to document chronic CO2 retention. If that is 
present, you may benefit from BiPAP with AVAPS during sleep. Medicare does not cover a home ventilator 
when used at settings that can be provided with BiPAP. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 9, 2022, 
through February 7, 2022, and from May 6, 2022, through June 4, 2022. 
 You asked the Plan to pay for the home health services. You say that the NOA was submitted multiple times. 
The Plan denied your request. The Plan says the NOA was not received timely. As such, this final claim was 
correctly denied. 
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start date of the first period of care is January 9, 2022. The NOA was not received by the Plan 
on a valid type of bill (TOB) until March 9, 2022. The start date of the second period of care is May 6, 2022. 
The NOA was not received by the Plan on a valid TOB until June 14, 2022. As more than 30 days passed 
between the timely filing date and the NOA receipt, no payment can be made on this claim. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from January 9, 2022, through 
February 7, 2022, and from May 6, 2022, through June 4, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic mobility scooter. 
 
You asked the Plan to pre-approve a mobility scooter. You say that you would benefit from using a scooter. 
The Plan denied your request. The Plan says that the requested scooter is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 mobility scooter. Our reviewer says 
that the coverage criteria has not been met. Our physician reviewer found that the documentation does not 
reveal a detailed upper extremity evaluation indicating why you are unable to use a manual wheelchair. The 
documentation does not reveal a detailed home evaluation indicating that you have adequate space to safely 
maneuver the requested device. The documentation does not reveal a detailed physician face-to-face visit 
supporting the need for the requested electric mobility scooter. 
 
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 mobility scooter have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an electronic mobility scooter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an occlusal guard  hard appliance, full arch (D9944).  
 
You asked the Plan to pre-approve the occlusal guard. You say that you doctor is asking you to wear this night 
guard to prevent injury and trauma to your mouth/tongue. The Plan denied your request. The Plan says this 
service is not covered under the benefit package. 
 
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. 
 
 
 
 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 pre-approve an 
occlusal guard  hard appliance, full arch (D9944).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle continuous glucose monitor (CGM) Mis 
Reader. 
 
You asked the Plan to pre-approve a Freestyle CGM reader. You say that the enrollee is diagnosed with 
diabetes mellitus and needs the requested CGM. The Plan denied your request. The Plan says the enrollee does 
not meet criteria for approval of the requested CGM. 
 
 The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections or require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of a Freestyle 
CGM reader have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle 
continuous glucose monitor (CGM) Mis Reader.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99417 billed for date of service January 27, 
2023. 
 
You asked the Plan to pay for procedure code 99417. You say that clinical documentation substantiates the 
billing. 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 99417 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 99417 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99417 billed for date of service January 27, 2023.