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

 
We decided that the Plan does not have to pre-approve vascular embolization (37243). 
 
You asked the Plan to pre-approve the procedure. You say that the enrollee's previous treatments have kept his 
disease under control and you are proposing repeating the treatment as it has shown to be effective in 
controlling his cancer. The Plan denied your request. The Plan says this service has not been medically proven 
to be effective and is therefore considered not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered. 
 
We looked at the file, and Medicare rules. Corporate Medical Policy (CMP) 7.01.69 requires patients to be 
enrolled in clinical trials to be eligible for this procedure. The enrollee is not currently enrolled in clinical trials. 
Based on this information, we decided that Medicare rules for coverage of the procedure have not been met. 
Therefore, we decided that the Plan does not have to pre-approve vascular embolization (37243).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Oxycodone-Acetaminophen (J8499). 
 
You asked the Plan to pre-approve Oxycodone-Acetaminophen. You say that the enrollee has been well 
controlled on this medication for several years. The Plan denied your request. The Plan says Oxycodone-
Acetaminophen is intended for self-administration. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Oxycodone-Acetaminophen 
(J8499).  
 
Benefits for Oxycodone-Acetaminophen may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and segmental 
pneumatic appliances (E0656, E0667). 
 
You asked the Plan to pre-approve a pneumatic compression device and appliances. You say that you are 
requesting an appeal regarding the denial of coverage for a Flexitouch pneumatic compression device. The Plan 
denied your request. The Plan says the enrollee does not meet the LCD criteria for an advanced lymphedema 
pump as there is no failed four-week trial of a basic pneumatic compression device of either E0650 or E0651. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652) and segmental pneumatic appliances (E0656, E0667).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda. 
 
You asked the Plan to pre-approve Keytruda. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the requested drug is not medically 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 Keytruda. Our reviewer says that the 
documentation does not support that the requested drug is medically reasonable or necessary. Our physician 
reviewer found you have a diagnosis of non small cell lung cancer. The record indicates that you have received 
therapy for more than 24 months with the requested agent. The record provided does not provide further 
information about your clinical condition. The Food and Drug Administration has not stated that the requested 
drug is indicated for your condition. The Medicare approved cancer drug compendia do not contain a 
supportive citation for the use of the requested drug in your clinical situation. Therefore, you do not meet 
criteria for the requested drug.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that the enrollee's medical needs are being met in the current acute 
setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. The patient 
appears to be stable but should only require short-term additional acute care services that can safely be 
completed at the current facility until more appropriate for a lower level of care. The patient does not require 
services at the LTACH that are not already available at the current facility. Our physician reviewer found that 
the enrollee's condition does not meet Medicare criteria for LTACH services. 
 
  
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) of the head or brain (70450) 
provided on March 3, 2022. 
 
You asked the Plan to pay for the CT scan. You say that this service was billed appropriately and was rendered 
in the place of service reported. The Plan denied your request. The Plan says the enrollee was inpatient at the 
time of services; therefore, this claim should be billed with an inpatient place of service (POS) code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate POS code. The rules say that, in a case where an enrollee is registered inpatient, the correct POS code is that of the appropriate inpatient POS code (at a minimum POS 
code 21) regardless of where the face-to-face service occurs. 
 
We find that the POS code billed on this claim (22 - On Campus, Outpatient Hospital) is not supported in the 
record. Specifically, the record shows that the enrollee was registered inpatient from February 28, 2022, to 
March 21, 2022. This means that the enrollee was inpatient status on the date in question, and therefore an 
inpatient POS code must be billed on this claim. Based on this information, we decided that Medicare billing 
rules have not been met. Therefore, we decided that the Plan does not have to pay for the computed 
tomography (CT) of the head or brain (70450) provided on March 3, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve arthrodesis, posterior or posterolateral technique, single 
level; lumbar (with lateral transverse technique, when performed) (22612) and posterior non-segmental 
instrumentation (eg, Harrington rod technique, pedicle fixation across one interspace, atlantoaxial transarticular 
screw fixation, sublaminar wiring at C1, facet screw fixation) (List separately in addition to code for primary 
procedure) (22840). 
 
You asked the Plan to pre-approve the surgical procedure. You say that the denial for this procedure is 
unwarranted and unsupported by the enrollee's current medical status and is inconsistent with currently 
accepted medical practice. The Plan denied your request. The Plan says this service is considered experimental 
and investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered.   
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the surgical procedure have not been met. Therefore, we decided that the Plan does not have to pre-
approve arthrodesis, posterior or posterolateral technique, single level; lumbar (with lateral transverse 
technique, when performed) (22612) and posterior non-segmental instrumentation (eg, Harrington rod 
technique, pedicle fixation across one interspace, atlantoaxial transarticular screw fixation, sublaminar wiring 
at C1, facet screw fixation) (List separately in addition to code for primary procedure) (22840).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home visit for assistance with activities of daily living 
and personal care (99509). 
 
You asked the Plan to pre-approve home attendant services. You say that you are currently getting home 
infusions. You also say you need home attendant services due to paralysis. The current home infusion services 
do not include custodial care; therefore, you are requesting a secondary agency to be allowed to provide these 
services. The Plan denied your request. The Plan says attendant services are a non-covered service. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of home attendant services have not been met. Specifically, we find that the services at issue in this 
case are considered custodial in nature. Therefore, we decided that the Plan does not have to pre-approve a 
home visit for assistance with activities of daily living and personal care (99509).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ophthalmology services to be provided by an out-of-
network (OON) provider at the in-network benefits. 
 
You asked the Plan to pre-approve ophthalmology services. You say that the enrollee requires these services 
due to stenosis of the right lacrimal canaliculi. The Plan denied your request. The Plan says the requested 
services can be provided by a network provider. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. Review of the file shows that the 
enrollee may receive services from the out-of-network provider; however, the enrollees cost share amounts 
will most likely be higher. The Plan has network providers available who can provide the items/services at 
issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services to be provided at the in-network benefit rates. Therefore, we decided that the Plan does not have to pre-approve 
ophthalmology services to be provided by an out-of-network (OON) provider at the in-network benefits.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (74230, 74240) provided on June 3, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not a covered 
place of service. 
 The Plan must follow Medicare rules. Medicare rules say that barium swallow studies are only payable for 
certain places of service.  
 
We looked at the file and Medicare rules. Per LCD L35433, a nursing home is not a covered place of service 
for a barium swallow study. 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 the services (74230, 
74240) provided on June 3, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on August 26, 2021 billed with 
codes 81206, 81292, and 81301. 
 
You asked the Plan to pay for the genetic testing billed. You say that the service was medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
August 26, 2021 billed with codes 81206, 81292, and 81301.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee cannot adequately be cared 
for at a skilled nursing facility because direct daily physician assessment is required. You say that the enrollee 
meets LTACH admission criteria under CMS guidelines and admission should be authorized. The Plan denied 
your request. The Plan says medical criteria for admission to an LTACH has not been met. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee does not require services at the LTACH that are not available at the 
current acute care hospital. 
 
 
  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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visit (99203), frames (V2020), anti-
reflective coating (V2750), progressive lens (V2781), and lens (V2782) provided on January 25, 2022. 
 
  You asked the Plan to pay for the outpatient office visit, frames, anti-reflective coating, progressive lens, and 
lens. You say that you believe there may be potential billing, coding, or processing errors. The Plan denied 
your request. The Plan says the $89.63 for the office visit applied to the deductible correctly. The Plan also 
says that you have exceeded the limits set in the subscriber agreement for the glasses. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $185 deductible which applies to routine vision services. Medicare 
generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and 
eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
The Plan covers up to a $400 combined allowance for eyeglasses and contact lenses every 24 months. 
 
The outpatient office visit you asked the Plan to pay for falls within the routine vision services benefit category. 
The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $185 deductible which 
applies to routine vision services. This cost sharing is a contractual obligation that had not been met at the time 
the outpatient office visit was received on January 25, 2022. The record shows that you received glasses on 
November 19, 2020, which was covered by the Plan. Therefore, we decided that the Plan does not have to pay 
for the outpatient office visit (99203), frames (V2020), anti-reflective coating (V2750), progressive lens 
(V2781), and lens (V2782) provided on January 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on April 13, 2022, 
by an OON provider. 
 
You asked the Plan to pay for a domiciliary or rest home visit. You say that you disagree with the denial. The 
Plan denied your request. The Plan says the out-of-network services were not authorized. 
 
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 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 a domiciliary or rest home visit provided on April 
13, 2022, by an OON provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 
You asked the Plan to pre-approve Euflexxa. You say that the required progression of treatments is an 
unnecessary burden. The Plan denied your request. The Plan says step therapy requirements have 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 Euflexxa. Our reviewer says that the 
requirements for coverage of Euflexxa have not been met. Our physician reviewer found the Plan requires a 
trial of Orthovisc, Synvisc, or Synvisc-One before they will approve the requested drug. The records show that 
you have not tried these drugs. The documentation does not support that Orthovisc, Synvisc, or Synvisc-One 
would likely be less effective or have adverse effects. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit provided on December 30, 2021, by an OON 
provider. 
 
You asked the Plan to pay for a home visit. You say that you are requesting a payment reconsideration. The 
Plan denied your request. The Plan says the out-of-network services were not authorized. 
 
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 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 a home visit provided on December 30, 2021, by 
an OON provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lower 
belly/pelvis for the enrollee. 
 
You asked the Plan to pre-approve the MRI. You say that this is needed to see if a prostate biopsy is needed. 
The Plan denied your request. The Plan says there was no reason given as to why a request for special MRI 
fusion ultrasound biopsy could not be performed in order to perform the required tissue biopsy. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 pre-approve the MRI. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found that the plan has 
indicated in the denial letter that MRI with fusion ultrasound would be considered in order to target for biopsy 
in a suspicious area. The enrollee has not had an abnormal digital rectal exam, nor have you had any random 
prostate biopsies. Thus, the medical necessity of MRI of the pelvis has not been established. The plan's 
alternative is a very reasonable approach, as it would allow targeted biopsy of any suspicious abnormality seen 
on the MRI thus optimizing patient 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 the MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve magnetic resonance imaging (MRI) of the lower belly/pelvis for the enrollee.