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

 
We decided that the Plan does not have to pre-approve the Allograft procedure. 
 
You asked the Plan to pre-approve the Allograft procedure. You say that the enrollee has attempted to alleviate 
pain with conventional treatment and has undergone failed interventional treatments. You say that the 
requested procedure is minimally invasive and will be used to relieve back pain and improve function. The 
Plan denied your request. The Plan says the type of procedure requested is not supported because research has 
not proven it to be helpful for the enrollee's condition. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Allograft procedure. Our reviewer 
says that the Allograft procedure is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Allograft procedure remains experimental in spinal surgery and more research is 
needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the Allograft procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Allograft procedure.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Neulasta Onpro (J2506). 
 
You asked the Plan to pre-approve Neulasta Onpro. You say that the services are necessary. The Plan denied 
your request. The Plan says based on the documentation provided, coverage criteria has not been met.  
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of 
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as 
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in 
Original Medicare and the plan cost-sharing for the same services. 
 
In this case, you asked the Plan to pre-approve Neulasta Onpro as part of a clinical trial. The Plan does not 
cover routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have 
to pre-approve Neulasta Onpro (J2506).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from 
Janaury 6, 2021, to January 9, 2021. 
 
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 DRG was downgraded from 871 to 603.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with D871 (SEPTICEMIA OR SEVERE SEPSIS 
WITHOUT MV >96 HOURS WITH MCC), which was not the appropriate DRG for this case. 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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our physician reviewer found DRG 603: CELLULITIS 
WITHOUT MCC was the appropriate DRG for the hospitalization.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided to the enrollee from Janaury 6, 2021, to January 9, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the anesthesia for radiological procedures (01922) provided September 
21, 2021. 
 
You asked the Plan to pay for the anesthesia services. You say that the claim denied as a non-covered service, 
but your coder states that it was coded correctly. Kindly reconsider for payment. The Plan denied your request. 
The Plan says that the services do not meet coverage requirements. 
 
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 pay for the anesthesia services. Our reviewer says 
that the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee with atrial fibrillation underwent transesophageal echocardiogram with 
cardioversion and no evidence of left atrial appendage thrombus. General anesthesia was administered during 
the procedure. The enrollee's condition was unstable with a severely reduced left ventricular systolic function 
and global hypokinesis with 20% ejection fraction and required more emergent cardioversion with anesthesia 
which is standard for this procedure. Therefore, based on the provided documentation, this request for 
anesthesia is medically necessary for this 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 the anesthesia services have been met. Therefore, we decided that the Plan has 
to pay for the anesthesia for radiological procedures (01922) provided September 21, 2021.  
 
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 pre-approve radiofrequency ablation (RFA) to the sacroiliac (SI) 
joint. 
 
You asked the Plan to pre-approve RFA to the SI joint. You say that this procedure is medically reasonable and 
necessary for the enrollee's condition. The Plan denied your request. The Plan says the requested procedure has 
not been proven to be as effective as the standard treatment of SI joint pain. 
 
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 RFA to the SI joint. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the requested RFA services are considered an experimental/investigational procedure 
because of the wide variation of efficacy reported in the literature. Therefore, the request is deemed not 
medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of RFA to the SI joint have not been met. Therefore, we decided that the Plan does 
not have to pre-approve radiofrequency ablation (RFA) to the sacroiliac (SI) joint.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography provided on January 3, 2022. 
 
You asked the Plan to pay for the computed tomography. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the services billed are not separately payable. 
 
 
 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 74176 
is a column II code to column I code 74178. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for the computed tomography provided on January 3, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for first-hour critical care (99291) provided on February 13, 2022. 
 
You asked the Plan to pay for critical care. You say that the services at issue were a medical necessity for the 
enrollee. The Plan denied your request. The Plan says that rules for payment have not been met because 
payment for the services at issue was included in a prior billed service. 
 
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. Specifically, the Plan has not provided support or explanation for their rationale 
that the services at issue were included a prior service. It is the Plan's responsibility to substantiate its denial. In 
this case, the denial has not been substantiated so we must find in your favor. Therefore, we decided that the 
Plan has to pay for first-hour critical care (99291) provided on February 13, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor supplies rendered on 
December 17, 2021. 
 
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 there is no valid physician order. 
 
The Plan must follow Medicare rules. The rules say that a supplier must have an order from the treating 
physician before dispensing any durable medical equipment (DME) item to a beneficiary. 
 
We looked at the file and Medicare rules. There is no valid physician order for the DME. 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 continuous glucose monitor supplies rendered on December 
17, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve services performed by a qualified physical therapist in 
the home health or hospice setting, each 15 minutes (G0151 x 8 visits), and services performed by a qualified 
occupational therapist in the home health or hospice setting, each 15 minutes (G0152 x 16 visits). 
 
You asked the Plan to pre-approve home health services. You say that your lack of progress is due to continued 
delays and denials. You say that weeks have pass between treatment and you lose and progress that was made. You also say that the services are medically necessary. The Plan denied your request. The Plan says the 
requested home health visits are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the requested home health services are not medically necessary. Our physician reviewer found you do 
not have documented skilled therapy needs. The reviewer found that you are functioning at or near your 
baseline. The reviewer found that your needs are custodial. Therefore, the reviewer found that the requested 
home health services are not medically necessary or reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve services performed by a qualified physical therapist in the home health or hospice 
setting, each 15 minutes (G0151 x 8 visits), and services performed by a qualified occupational therapist in the 
home health or hospice setting, each 15 minutes (G0152 x 16 visits).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services rendered on August 17, 2021. 
 
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 44144 is not separately payable. 
 
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 44144 is a column II code to column I code 44160. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for the surgical services rendered on August 17, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Hereditary cardio screen panel coded as 81161, 81251, 
81256, 81286, 81400, 81410, 81411, 81413, 81414 provided June 10, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the CPT codes were denied for medical 
records. The medical records have been attached to this appeal. Please reconsider the charges which were 
previously denied. The Plan denied your request. The Plan says the records do not support medical necessity. 
 
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 pay for the laboratory services. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found it was reported that the enrollee had shortness of breath and localized edema. 
However, the enrollee is already at a statistically and clinically high risk of cardiac event regardless of the 
results of genetic testing based on his age and medical history and would not change the treatment options for 
this enrollee. Also, there is insufficient supportive studies to show this testing panel leads to improved 
outcomes for patients to justify this request. Therefore, the gene testing will be considered 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 laboratory services have not been met. Therefore, we decided that the Plan 
does not have to pay for Hereditary cardio screen panel coded as 81161, 81251, 81256, 81286, 81400, 81410, 
81411, 81413, 81414 provided June 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a prosthetic leg with a microprocessor knee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the requested computerized knee exceeds medical needs. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that in this case, the health plan has authorized a prosthesis with a K3 level mechanical knee.  It is not 
clearly documented why a microprocessor knee would be required. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a prosthetic leg with a microprocessor knee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit on December 10, 2020, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for the office visit. You say that you are appealing the claim payment denial. The 
Plan denied your request. The Plan says the services were provided out-of-network and were not approved in 
advanced. 
 
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 had network providers 
available who could have provided the office visit at issue in this appeal. The Plan did not pre-approve the 
office visit at issue. We found no exception that would require the Plan to pay for the office visit. Therefore, we 
decided that the Plan does not have to pay for office visit on December 10, 2020, by an out-of-network (OON) 
provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of an interlaminar/interspinous process 
stabilization/distraction device for the enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says testimonials indicating such limited acceptance, and limited case studies distributed by 
sponsors with financial interest in the outcome, are not sufficient evidence of general acceptance by the 
medical community. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that these interlaminar spinous process devices remain experimental. More research is needed to show 
safety and efficacy. 
 
 
 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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve insertion of an interlaminar/interspinous process stabilization/distraction device for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable wireless pulmonary artery pressure 
monitoring device (33289). 
 
You asked the Plan to pre-approve an implantable wireless pulmonary artery pressure monitoring device. You 
say that the requested device is medically necessary. The Plan denied your request. The Plan says the requested 
device does not meet criteria. 
 
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 an implantable wireless pulmonary 
artery pressure monitoring device. Our reviewer says that the requested items/services are not considered 
medically reasonable and necessary in this case. Our physician reviewer found the clinical study on which the 
FDA approval was based showed improved clinical outcomes and decreased hospitalizations in patients in 
whom the CardioMEMS system was implanted, reflecting a patient population with preserved ejection fraction. 
There remains a dearth of randomized, blinded clinical studies examining long-term clinical outcomes 
establishing the value of CardioMEMS in patient management. As a result, at this time the CardioMEMS 
system would not be considered medically appropriate and necessary in this patients clinical management. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an implantable wireless pulmonary artery pressure monitoring device have not 
been met. Therefore, we decided that the Plan does not have to pre-approve an implantable wireless pulmonary 
artery pressure monitoring device (33289).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CxBladder testing provided on September 22, 2021. 
 
You asked the Plan to pay for the testing services. You say that the test rules out bladder cancer in those with a 
risk. The Plan denied your request. The Plan says the testing is not medically necessary. 
 The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
We looked at the file and the rules. Services used to detect an undiagnosed disease or disease predisposition are 
not a Medicare benefit and are not covered. The testing services were requested for screening purposes. 
Medicare does not cover this testing for screening purposes. Therefore, we decided that the Plan does not have 
to pay for the CxBladder testing provided on September 22, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc-One injections. 
 
You asked the Plan to pre-approve Synvisc-One injections. You say that nothing has worked to relieve your 
pain. The Plan denied your request. The Plan says this is not covered for your condition. 
 
The Plan must follow Medicare rules. Medicare rules say that purified natural hyaluronans have been approved 
by the Food and Drug Administration (FDA) for the treatment of pain associated with osteoarthritis of the 
knee. In addition to the FDA approved use, hyalurons have been recognized as a therapeutic option in 
osteoarthritis of the shoulder. 
 
We looked at the file and Medicare rules. The record shows that the injections at issue have been requested for 
treatment of osteoarthritis of the hip, which is not a covered indication. Based on this information, we decided 
that Medicare rules for coverage of Synvisc-One injections have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Synvisc-One injections.