Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories.
You asked the Plan to pre-approve the group 3 power wheelchair. You say that you would like reconsideration
because the wheelchair is medically necessary. The Plan denied your request. The Plan says the member does
not meet coverage criteria as they do not have a primary neurologic condition, myopathy or congenital skeletal
deformity.
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 patient's 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 the group 3 power wheelchair. Our
reviewer says that the member does not meet Medicare coverage criteria for the group 3 power wheelchair. Our
physician reviewer found the documentation does not reveal evidence of a severe afflicted disease such as
neuron disease (i.e. Amyotrophic Lateral Sclerosis), spinal cord injury resulting in quadriplegia, stroke (CVA)
with hemiplegia, late stage Parkinson's, late stage Multiple Sclerosis (MS), cerebral palsy or a myopathy or
muscular dystrophy.
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 group 3 power wheelchair have not been met. Therefore, we decided that the
Plan does not have to pre-approve a group 3 power wheelchair and accessories.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services rendered from
August 6, 2019 to August 31, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services were not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed above 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 pay for these services. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found the enrollee was referred to occupational
therapy (OT) for exacerbation of need for assistance from others. She was discharged from OT on August 20,
2019 for meeting her goals.
The physical therapist's note on August 28, 2019 states she had achieved her highest functional level. She had
no skilled nursing or skilled therapy needs. She did not need skilled nursing or skilled therapy on a daily basis.
As a practical matter, the enrollee did not require the necessary services on an inpatient basis at the SNF 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 these services have not been met. Therefore, we decided that the Plan does not
have to pay for the skilled nursing facility (SNF) services rendered from August 6, 2019 to August 31, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for catheter placement (36245) provided on November 22, 2019.
You asked the Plan to pay for the catheter placement. You say that you would like reconsideration based on the
records submitted. The Plan denied your request. The Plan says the documentation submitted does not support
the service 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 code 36245 is selective catheter placement, arterial system;
each first order abdominal, pelvic, or lower extremity artery branch, within a vascular family
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 catheter placement. Our reviewer says that CPT code
36245 does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical
records provided do not include documentation to support a Selective catheter placement, arterial system; each
first order abdominal, pelvic, or lower extremity artery branch, within a vascular family being performed on
November 22, 2019 therefore this service cannot be verified.
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 catheter placement have not been met. Therefore, we decided that the Plan
does not have to pay for catheter placement (36245) provided on November 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia services (00840 QZ) provided on October 13,
2019.
You asked the Plan to pay for the anesthesia services. You say that you would like reconsideration as this
service was billed correctly. The Plan denied your request. The Plan says this claim was not billed with an
appropriate modifier.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
We find that CPT code 00840 QZ is not supported in the record. Specifically, the record indicates that this
service was provided with the medical direction of an anesthesiologist. The QZ modifier indicates that the
CRNA rendered services without medical direction by a anesthesiologist. In this case, billing the QZ modifier
is inappropriate. Based on this information, we decided that Medicare rules for coverage of the anesthesia
services have not been met. Therefore, we decided that the Plan does not have to pay for anesthesia services
(00840 QZ) provided on October 13, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from November 3,
2019 through November 4, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary. The
Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases,
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or
more.
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 acute inpatient hospital care. Our reviewer
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our
physician reviewer found the review has determined that the record did not show that at the time of inpatient
admission the admitting physician reasonably expected that the patient's necessary hospital care (including
earlier emergency department (ED) and/or observation care) would span two midnights.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the
Plan does not have to pay for the acute inpatient hospital care provided from November 3, 2019 through
November 4, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CardioMEMS system for the enrollee.
You asked the Plan to pre-approve a CardioMEMS system. You say that this is medically reasonable and
necessary for this enrollee. The Plan denied your request. The Plan says that this device is investigational.
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 a CardioMEMS system. Our reviewer
says that the requested items/services are not considered medically reasonable and necessary in this case. In
this circumstance therapy change based on data obtained from a CardioMEMs device has been demonstrated in
only one trial to help reduce hospital readmission compared to standard medical therapy. Moreover, concerns
have been raised about potential bias in this trial calling into question the results. Therefore, the efficacy of the
CardioMEMS device is uncertain at this time according to leading authorities and not recommended in current
guidelines for the treatment of heart failure. Medicare coverage criteria are not met, in my opinion, since the
device should still be considered experimental or investigational. Our physician reviewer found that Medicare
coverage criteria are not met since the device should still be considered experimental or investigational.
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 CardioMEMS system have not been met. Therefore, we decided that the Plan
does not have to pre-approve a CardioMEMS system for the enrollee.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Gel-one (J7326).
You asked the Plan to pre-approve Gel-one. You say that the requested medication is necessary. The Plan
denied your request. The Plan says that based on the documentation provided, coverage criteria has not been
met.
The Plan follows Medicare rules. Medicare rules say that a repeat series of injections may be allowed when
certain criteria is met.
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 Gel-one. Our reviewer says that the
medication is medically necessary. Our physician reviewer found the enrollee achieved more than 6 months of
relief from the prior Gel one injection. Therefore, it is medically reasonable and necessary for the enrollee to
receive another.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Gel-one have been met. Therefore, we decided that the Plan has to pre-approve
Gel-one (J7326).
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the setup and operation of the heart lung machine by a
perfusionist.
You asked the Plan to pay for the perfusionist services. You say that it takes a half hour to an hour to set up the
heart lung machine. You say that the perfusionist is required to be in the operating room during the length of
the procedure. You say that it is mandatory that the surgeon, anesthesiologist, and perfusionist transport the
enrollee to the unit and be there until the enrollee is in stable condition. You say that the medical records
provided support the need for the services in dispute. The Plan denied your request. The Plan says the services
in dispute are included in the facility DRG payment. The Plan says that the payment for this service is the
responsibility of the facility to any vendor.
The Plan must follow Medicare rules. Medicare rules say all items and non-physician services furnished to
inpatients must be furnished directly by the hospital or billed through the hospital under arrangements.
Although these services may be appropriate, payment for them is made to the hospital which must then furnish
these services either directly or under arrangements. As such, separate Medicare payment cannot be made for
the services at issue. Therefore, we decided that the Plan does not have to pay for the setup and operation of the
heart lung machine by a perfusionist.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the medical eye exam provided on January
16, 2020.
You asked the Plan to waive the copayment for the medical eye exam. You say that you should not have a
copayment since you need this service every six months for your eye condition. The Plan denied your request.
The Plan says you have been charged the correct cost sharing amount.
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 $45
copayment for Medicare-covered eye exams, including diagnosis and treatment for diseases and conditions of
the eye.
You have been asked to pay a $45 copayment for the medical eye exam. The medical eye exam falls within the
"Vision care" benefit category. The record shows diagnoses of retinal disorders, diabetes, and age-related
cataracts which makes the eye exam medical in nature.
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 the medical eye exam provided on January 16, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on
November 18, 2019.
You asked the Plan to pay for the pump assembly and operation. You say that you would like reconsideration
based on the records submitted. The Plan denied your request. The Plan says payment for this service is the
responsibility of the facility to any vendor.
The Plan must follow Medicare rules. Medicare rules say that Medicare does not pay any provider or supplier
other than the facility or hospital for services furnished to the beneficiary while an inpatient.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the pump assembly and operation have not been met. Specifically, payment for this service is
included in the DRG payment to the facility and is the responsibility of the facility to any vendor. Therefore,
we decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on
November 18, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Lutathera and Octreotide depot for the enrollee.
You asked the Plan to pre-approve Lutathera and Octreotide depot. The Plan denied your request. The Plan
says that they did not receive documentation indicating that the enrollee meets standards for coverage of these
drugs.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer
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 Lutathera and Octreotide depot. Our
reviewer says that Lutathera and Octreotide depot are not medically reasonable and necessary for the enrollee
in this case. The submitted documentation includes both primary lung cancer and primary pancreatic
neuroendocrine cancers. Pathology of retroperitoneal mass and adrenal glands indicate high grade
neuroendocrine cancer. Gallium Netspot imaging, which is done with Gallium Dotatate to detect somatostatin
positive tumors showed mildly hypermetabolic adenopathy in the abdomen and chest lymph nodes. No
significant uptake was seen in the small pancreatic lesion. The report indicates background physiologic uptake
is roughly 3.0. The positive nodes have uptake ranging from 3.4 to 4.9. Therefore, the tumor is somatostatin
receptor positive. Per the FDA website, Lutathera is indicated for the treatment of somatostatin receptorpositive
gastroenteropancreatic neuroendocrine tumors (GEP-NETs), including foregut, midgut, and hindgut
neuroendocrine tumors in adults. Drug-Dex, Lexidrugs and Clinical Pharmacology also support the use without
any statement about previous treatments. NCCN Compendium recommends the use when there has been
progression on treatment with Octreotide or Lanreotide. The enrollee has had neither of those drugs.
The NCCN Guidelines Version 1.2019 Neuroendocrine and Adrenal Tumors page NE-E 1 of 3 lists key
eligibility for Lutathera as low- or intermediate-grade NET. Therefore the documentation does not support that
the requested regimen including Lutathera and Octreotide depot, is safe and effective, nor medically reasonable
and necessary for the enrollee. Our physician reviewer found that the enrollee's condition does not meet criteria
for coverage of these drugs.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Lutathera and Octreotide depot have not been met. Therefore, we decided that
the Plan does not have to pre-approve Lutathera and Octreotide depot for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a DaT scan.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. 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 these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the enrollee is noted to have symptoms
readily consistent with Parkinson's Disease with a potential differential diagnosis of drug induced
Parkinsonism. The evidence to date on the use of DaT scans show good specificity for diagnosing Parkinson's
disease in patients with Parkinsonian symptoms; however, there is less sensitivity for ruling out disease.
Further clinical trials are needed to determine efficacy of the DaT scan. The services are therefore not
reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve a DaT scan.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the out of network chiropractic services provided to the
enrollee from December 18, 2019 to December 23, 2019.
You asked the Plan to pay for out of network chiropractic services. You say that this claim should be paid. The
Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.
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 in this case is not a network provider with the Plan. The Plan has network providers available
who can provide the services at issue in this appeal. The Plan did not pre-approve the service 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 the out of network chiropractic services provided to the enrollee from December 18,
2019 to December 23, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the testing services rendered on November 15, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says procedure code 95999 is not supported.
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 95999 is unlisted neurological or neuromuscular
diagnostic procedure.
We find that CPT code 95999 is not supported in the medical record. Specifically, the file shows that Train of
Four testing was performed and there is a more appropriate code for these services. Based on this information,
we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that
the Plan does not have to pay for the testing services rendered on November 15, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the DME purchased on November 20, 2019 from an out-ofnetwork
provider.
You asked the Plan to pay for the DME. You say that the durable medical equipment is medically necessary.
The Plan denied your request. The Plan says you do not have out-of-network benefits.
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 has network providers
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for the DME purchased on November 20, 2019 from
an out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the sodium hyaluronate knee injection provided in India on
November 29, 2019.
You asked the Plan to pay for the drug injection. You say that you feel that this drug should be covered since it
was required to treat your condition. The Plan denied your request. The Plan says this drug is not covered
outside of the US.
The Plan must follow Medicare rules. Medicare rules say that, with few exceptions, services provided outside
of the US are not covered. Your Plan offers a benefit which goes beyond this coverage. For this reason, the
Plan's rules apply.
It is noted that emergency and urgently needed services are covered outside of the US. However, the rules state
that only emergency medications may be covered. The use of this drug is not considered emergent because a
prudent layperson would not believe that his or her health would be in serious jeopardy without the immediate
use of this drug. As this is not considered an emergency medication, it does not meet the rules for coverage
under your plan's supplemental benefit. Therefore, we decided that the Plan does not have to pay for the
sodium hyaluronate knee injection provided in India on November 29, 2019.