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

 
We decided that the Plan does not have to pay for the prostate cancer screening (G0103) provided on 
September 30, 2022. 
 
You asked the Plan to pay for the prostate cancer screening. You say that this additional screening was 
medically necessary. The Plan denied your request. The Plan says prostate cancer screenings are covered once 
every 12 months for eligible individuals. You previously had a covered screening on July 18, 2022, which was 
covered at that time. 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. Your contract with the Plan states that prostate cancer 
screenings are covered once every 12 months. 
 
We looked at the file, Medicare rules and the Plans rules. You previously had a prostate cancer screening on 
July 18, 2022. The record shows that this exam was covered by the Plan. Twelve months have not passed 
between this exam and the exam at issue. Based on this information, we have decided that the rules for 
coverage of a prostate cancer screening have not been met in this case. Therefore, we decided that the Plan 
does not have to pay for the prostate cancer screening (G0103) provided on September 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core buildup, including any pins when required (D2950), 
extraction, erupted tooth requiring removal of bone and/or sectioning of tooth (D7210), retainer crown - 
porcelain/ceramic (D6740), and retainer crown - porcelain/ceramic (D6245 x2) provided on May 10, 2022, and 
May 13, 2022. 
 
You asked the Plan to pay for the dental services. You say that your decision was based on what your cost 
would be after insurance payments. You also say that if you had known that this provider was not in-network 
you would have chosen another provider. The Plan denied your request. The Plan says the dental services were 
received from an out-of-network provider and are not covered by your supplemental benefits. 
 
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 record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for core buildup, including any pins when required (D2950), extraction, erupted tooth requiring removal 
of bone and/or sectioning of tooth (D7210), retainer crown - porcelain/ceramic (D6740), and retainer crown - 
porcelain/ceramic (D6245 x2) provided on May 10, 2022, and May 13, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 72125 billed for date of service June 26, 
2022. 
 
You asked the Plan to pay for procedure code 72125. You say that this claim was denied in error. 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 submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 72125 is 1. The MAI value for this code is 3. You billed 2 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 72125 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 72125 billed for date of service June 26, 2022.
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 June 27, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that there is no contractual 
agreement between the laboratory and the dialysis facility for payment. 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 June 27, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee would like reconsideration because the 
services are medically necessary. The Plan denied your request. The Plan says a SNF admission is not 
medically necessary, and the enrollee's needs can be met at a lower level of care 
 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 that the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing or skilled therapy on an inpatient basis in a 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 SNF care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 85060 billed for date of service August 18, 
2022. 
 
You asked the Plan to pay for procedure code(s) 85060. The Plan denied your request. The Plan says this code 
is included in the facility payment and is not separately payable. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
Per the Physician Fee Schedule, there is a Professional/Technical indicator of 8 for CPT code(s) 85060. No TC 
billing is recognized because payment for the underlying clinical laboratory test is made to the hospital, 
generally through the Hospital Fee Schedule payment rate. No payment is recognized for CPT code 85060 
furnished to hospital outpatients or non-hospital patients. Based on this information, we decided that Medicare 
rules for coverage of procedure code 85060 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code(s) 85060 billed for date of service August 18, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a VIA Disc allograft intervertebral disc augmentation 
procedure (0627T). 
 
You asked the Plan to pre-approve a VIA Disc allograft intervertebral disc augmentation procedure. You say 
that based on the enrollee's clinical condition and review of the supporting documentation, you are confident it 
will be agreed that the VIA Disc allograft procedure is appropriately indicated for the enrollee. The Plan denied 
your request. The Plan says the clinical value and effectiveness of the VIA Disc allograft intervertebral disc 
augmentation in the setting of degenerative disc disease (DDD), lumbar spondylosis, and chronic low back pain 
have not been demonstrated in the peer-reviewed literature. 
 
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 VIA Disc allograft intervertebral disc 
augmentation procedure. Our reviewer says that the requested VIA Disc allograft intervertebral disc 
augmentation procedure is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the provider is requesting the injection of VIA Disc into the spinal disc for advanced 
degenerative disc disease against Food and Drug Administration approval guidelines. Our reviewer found large 
well-designed studies in the peer review scientific literature comparing stand-alone use of VIA Disc to 
established treatments are needed. Our physician reviewer also found that published studies do not demonstrate 
any long-term health outcome advantage with the use of VIA Disc NP as an alternative to standard treatments. 
 
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 VIA Disc allograft intervertebral disc augmentation procedure have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a VIA Disc allograft intervertebral disc 
augmentation procedure (0627T).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heavy-duty hospital bed, extra wide, with weight 
capacity greater than 350 pounds, but less than or equal to 600 pounds, with any type of side rails, with 
mattress (E0303). 
 
You asked the Plan to pre-approve a heavy-duty hospital bed. You say that you have been denied twice for a 
specialty hospital bed as you cannot get in and out of bed. The Plan denied your request. The Plan says you do 
qualify for a regular hospital bed, however, this specific type of bed requires your weight to be more than 350 
pounds but less than 600 pounds. You do not qualify for the requested bed. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
 
 
 We looked at the file and Medicare rules. The LCD confirms that the requested bed is covered for enrollees 
who weigh 350 to 600 pounds. Your records show you weigh 340 pounds; therefore, you do not qualify for this 
requested heavy duty bed. Based on this information, we decided that Medicare rules for coverage of a heavy-
duty hospital bed have not been met. Therefore, we decided that the Plan does not have to pre-approve a heavy-
duty hospital bed, extra wide, with weight capacity greater than 350 pounds, but less than or equal to 600 
pounds, with any type of side rails, with mattress (E0303).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the spine surgery (CPT code(s): 20930, 20936, 22614, 
22633, 22634, 22842, 22853, 61783, 63012, 63052, 63053). 
 
You asked the Plan to pre-approve the surgical services. You say that the services are necessary. The Plan 
denied your request. The Plan says the surgery is not 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 surgical services. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the criteria for spine surgery are not met. There has not been a recent trial and failure 
of physical therapy (PT) for back pain. 
 
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 surgical services have not been met. Therefore, we decided that the Plan does not have to pre-approve the spine surgery (CPT code(s): 20930, 20936, 22614, 22633, 22634, 22842, 
22853, 61783, 63012, 63052, 63053).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom fabricated wheelchair seat cushion (E2609), a 
custom fabricated wheelchair back cushion, any size, including any type mounting hardware (E2617), a 
headrest (E0955), a manual swingaway, retractable or removable mounting hardware for joystick (E1028) and 
repair or nonroutine service for durable medical equipment (K0739x3). 
 
You asked the Plan to pre-approve wheelchair accessories. You say that the requested accessories are 
medically necessary for the enrollee. The Plan denied your request. The Plan says Medicare guidance says 
coverage cannot be provided for equipment used in an institution classified as a long-term care facility. 
Medicare says durable medical equipment must be for use in the enrollee's residence other than a health care 
institution. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
 
 
 Records show that wheelchair accessories is being requested for use in a SNF or hospital. Therefore, we 
decided that the Plan does not have to pre-approve a custom fabricated wheelchair seat cushion (E2609), a 
custom fabricated wheelchair back cushion, any size, including any type mounting hardware (E2617), a 
headrest (E0955), a manual swingaway, retractable or removable mounting hardware for joystick (E1028) and 
repair or nonroutine service for durable medical equipment (K0739x3).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that the requested home ventilator is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested 
home ventilator. 
 
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 enrollee does not meet criteria for the requested home ventilator. Our physician reviewer found the 
enrollee has severe chronic obstructive pulmonary disease (COPD) and was recently hospitalized with an 
exacerbation. An arterial blood gas (ABG) test was consistent with acute on chronic hypercarbic respiratory 
failure. This enrollee may benefit from BiPAP with AVAPS during sleep as an outpatient. The records do not show that this has been tried as an outpatient. Medicare does not cover a home ventilator when used as BiPAP. 
Battery backup and alarms 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 a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Trazimera (Q5116) to be used in combination with 
Folfox and Bevacizumab. 
 
You asked the Plan to pre-approve Trazimera. You say that the enrollee has been treated with Trazimera and 
has had a great response. The Plan denied your request. The Plan says the use of this drug/regimen is not 
reasonable and necessary. 
 
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 Trazimera. Our reviewer says that 
Trazimera to be used in combination with Folfox and Bevacizumab is not reasonable and necessary for the 
enrollee. Our physician reviewer found the requested use of Trazimera is not FDA-approved for the enrollees 
diagnosis. The use is not supported by one of the major drug compendia or by clinical research that appears in a 
Centers for Medicare and Medicaid Services (CMS) approved medical journal. Our reviewer found that 
treatment recommended for colorectal cancer, metastatic, HER2 overexpressing, with progression on 
conventional chemotherapy, but this enrollee has stable disease. Our physician reviewer also found that the use 
is not listed as not indicated, not supported or not recommended in the compendia.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Trazimera have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Trazimera (Q5116) to be used in combination with Folfox and Bevacizumab.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the lightweight wheelchair (CPT code K0003). 
 
You asked the Plan to pre-approve the lightweight wheelchair. You say that you have no quality of life, you are 
unable to walk because you have five (5) bad discs in your back. The Plan denied your request. The Plan says 
Medicare requires several things to approve coverage of a wheelchair. The Plan states that information was not 
provided. 
 
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 lightweight wheelchair. Our 
physician reviewer found without a detailed upper extremity physical examination it is not clear why you are 
unable to self-propel a standard wheelchair. The documentation indicates you want a lightweight wheelchair, 
but there has been no trial of a standard or lightweight wheelchair in the documentation. 
 
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 lightweight wheelchair have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the lightweight wheelchair (CPT code K0003).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve shoulder arthroscopy. 
 
You asked the Plan to pre-approve shoulder arthroscopy. You say that the requested shoulder arthroscopy is 
medically necessary. The Plan denied your request. The Plan says the requested shoulder arthroscopy is 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 shoulder arthroscopy. Our reviewer 
says that the requested shoulder arthroscopy is not medically necessary. Our physician reviewer found the 
enrollee was being treated for a complete rotator cuff tear or rupture of the left shoulder. She presented with 
bilateral shoulder pain. She notes the left shoulder pain has been worsening over the past several months. She is 
unable to use her left upper extremity due to pain. The exam of the left shoulder reveals 4-/5 strength with 
abduction and external rotation. 
 
However, detailed documentation is not evident regarding a symptomatic irreparable posterosuperior rotator 
cuff tear. There are limited large-scale, long-term references showing the safety and efficacy of the requested surgery in this clinical setting. There is no compelling rationale presented or extenuating circumstances noted 
to support the medical necessity of this request as an exception. Therefore, the requested left shoulder 
arthroscopy, capsulorrhaphy, in this case, is 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 shoulder arthroscopy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve shoulder arthroscopy.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ilumya. 
 
You asked the Plan to pre-approve Ilumya. 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. 
 
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 Ilumya. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the documentation does not support that 
Inflectra or Remicade would likely be less effective, and/or would likely have adverse effects for the enrollee 
in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Ilumya have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Ilumya.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this procedure fills a treatment gap for 
patients that do not receive adequate relief from traditional conservative methods. You say that the enrollee 
tried conservative treatment without relief and you disagree with denial. The Plan denied your request. The 
Plan says Medicare does not cover unproven and not medically necessary procedures. 
 
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 Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Intracept procedure is experimental, 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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.