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

 
We decided that the Plan has to pay for procedure code Q0508 provided on May 19, 2022. 
 
You asked the Plan to pay for the services provided. You say that the code should be reimbursed. The Plan 
denied your request. The Plan says that the code has not met the associated diagnosis code relationship criteria. 
 
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. 
 
We looked at the file and the rules. The National Coverage Determination for ventricular assist devices, 20.9.1, 
the Plan used in their decision to deny services does not include diagnosis codes. The Local Coverage Article 
for the billing and coding of ventricular assist device supplies and accessories, A54910, also does not include 
diagnosis codes that either support or do not support medical necessity. The billed diagnosis code, Z95.811  
presence of a heart assist device, is a reasonable diagnosis code for the supplies at issue in this case. The Plan 
has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to 
deny your request.  Therefore, we decided that the Plan has to pay for procedure code Q0508 provided on May 
19, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 36907 billed for date of service June 30, 
2022. 
 
You asked the Plan to pay for procedure code 36907. The Plan denied your request. The Plan says payment for 
code 36907 is bundled into payment for code 37248.  
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 36907 
is a column II code to column I code 37248. Based on the claim submitted, Medicare billing criteria have not 
been met. Therefore, we decided that the Plan does not have to pay for procedure code 36907 billed for date of 
service June 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vertiflex Superion device (22869). 
 
You asked the Plan to pre-approve Vertiflex. You say that the requested service is medically necessary for the 
enrollee. You also say that their pain has greatly impacted their quality of life. The Plan denied your request. 
The Plan says the requested service 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 Vertiflex. Our reviewer says that the 
requested Vertiflex device is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the requested Vertiflex device is considered experimental. Therefore, the reviewer found that 
the requested Vertiflex device 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 Vertiflex have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Vertiflex Superion device (22869).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the electrical connection between the wheelchair 
controller and two or more motors (E2311), expandable controller (E2377), harness (E2313), and power seat 
elevation system (E2300). 
 
You asked the Plan to pre-approve the power wheelchair accessories. You say that the items are medically 
necessary. The Plan denied your request. The Plan says the items are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that plans must pay for a medical service or item if 
regular Medicare would pay for it in 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 pre-approve the power wheelchair accessories. Our 
reviewer says that these items are not medically necessary. Our physician reviewer found the member does 
have use of the upper extremity and can operate and control the power options using the switches that are 
included in the basic wheelchair. 
 
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 power wheelchair accessories have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the electrical connection between the wheelchair controller and two or 
more motors (E2311), expandable controller (E2377), harness (E2313), and power seat elevation system 
(E2300).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hyaluronan or derivative, hyalgan, supartz or visco-3, for 
intra-articular injection, per dose (J7321 X 25) provided on May 17, 2022. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says CPT J7321 was not billed in accordance with Medicare National Correct Coding Initiative 
Policy - Medically Unlikely Edits (MUE). 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the service have not been met. CPT J7321 has an MUE value of 
"2", Provider billed "25" units. Therefore, we decided that the Plan does not have to pay for the hyaluronan or derivative, hyalgan, supartz or visco-3, for intra-articular injection, per dose (J7321 X 25) provided on May 17, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on 
September 23, 2021. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you disagree with the 
copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 physician/practitioner services/specialist.  
 
You have been asked to pay a $45 copayment for a specialist office visit. This item/service falls within the 
physician/practitioner services/specialist benefit category. 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 a specialist office visit provided on September 23, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on June 18, 2022. 
 
You asked the Plan to pay for the lab services. You say that the results provide treatment options. The Plan 
denied your request. The Plan says the enrollee does not meet the requirements for approval. 
 The Plan must follow Medicare rules. Medicare rules say that next generation sequencing is only covered under 
certain medical indications.  
 
We find that the testing at issue is not supported in the medical record. The records do not show that the 
enrollee has either recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer. Based on this 
information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we 
decided that the Plan does not have to pay for the lab testing services provided on June 18, 2022.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pay for the Alimta (Pemetrexed) (J9305) and chemotherapy administration 
(96409) provided on May 23, 2022. 
 
You asked the Plan to pay for the Alimta and chemotherapy administration. The Plan denied your request. The 
Plan says that the clinical value and effectiveness of Alimta (Pemetrexed) in the setting of neuroendocrine 
tumors have not been demonstrated in the peer-reviewed literature. 
 
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 pay for the Alimta and chemotherapy 
administration. Our reviewer says that the Alimta and chemotherapy administration was medically reasonable 
and necessary for the enrollee. Our physician reviewer found the requested use of Alimta is FDA-approved for 
the enrollees diagnosis, as single-agent treatment (after prior chemotherapy) of recurrent/metastatic non-
squamous non-small cell lung cancer. Our reviewer also found that the documentation does support that the 
requested drug is safe and effective and otherwise reasonable and 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 Alimta and chemotherapy administration have been met. Therefore, we 
decided that the Plan has to pay for the Alimta (Pemetrexed) (J9305) and chemotherapy administration (96409) 
provided on May 23, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional critical care services (procedure code 99292) 
provided to the enrollee on April 7, 2022. 
 
You asked the Plan to pay for the services. You say that this add-on code is payable with CPT 99291. The Plan 
denied your request. The Plan says CPT 99292 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 99292 is "Critical care, evaluation and management of 
the critically ill or critically injured patient; each additional 30 minutes (List separately in addition to code for 
primary service)." 
 
We find that CPT code 99292 is not supported in the medical record. Specifically, two separate providers 
provided critical care services for a total of 75 minutes aggregate. In this instance, CPT 99292 would only be 
used if a full 30 minutes above the first 74 minutes was rendered. 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 additional critical care services (procedure code 99292) provided to the enrollee on April 7, 
2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia (J0897). 
 
You asked the Plan to pre-approve Prolia. The Plan denied your request. The Plan says this request does not 
meet the Plan's Part B coverage criteria for Prolia. 
 
 
 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 Prolia. Our reviewer says that the 
enrollee does not meet the criteria for coverage for Prolia. Our physician reviewer found there is no indication 
that the enrollee has tried and failed the required drug. Our reviewer also found that there is no indication that 
the Plan's required drug would likely be less effective and/or likely have adverse effects for the 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 Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia (J0897).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting inpatient rehabilitation services. 
The Plan denied your request. The Plan says you do not meet the Medicare criteria for admission to an IRF. 
Your care can be treated at a lower level of care such as skilled nursing facility. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found there are no complex nursing or rehabilitation needs. While you have a need for 
physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. 
 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Privigen. 
 You asked the Plan to pre-approve Privigen. You say that the requested drug is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the requested drug is not covered under Medicare Part B 
when the enrollee is participating in a clinical trial. 
 
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 Privigen 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 Privigen.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex procedure. 
 
You asked the Plan to pre-approve the Vertiflex procedure. You say that this procedure is not medically 
reasonable and necessary. The Plan denied your request. The Plan says the requested procedure is considered 
experimental/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 the Vertiflex procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that this 80-year-old female was being treated for spinal stenosis of the lumbar region 
with neurogenic claudication. She presented with low back pain with radiation to the bilateral legs. The pain 
level is 5/10. The exam reveals she ambulates with a cane and an antalgic gait. There is diffuse lumbar 
paraspinal tenderness to palpation. There is increased pain with extension and rotation. There is tenderness to 
palpation of the bilateral SI notch. There is a positive shopping cart sign.  
 
However, current evidence based medical guideline and peer reviewed literature do not fully support the spinal 
decompression device procedure over the gold standard of lumbar laminectomy. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollees medical 
condition. 
 
Food and Drug Administration (FDA) indications include implantation of the Superion device at one or two 
adjacent lumbar levels in patients with moderate spinal stenosis in whom operative treatment is indicated at no 
more than two levels, from L1 to L5. This enrollee has multiple degrees of spinal stenosis, many not at FDA 
indicated levels of moderate spinal stenosis (plausibly including the planned level of implantation L3/4 and 
L4/5.) There was no formal magnetic resonance imaging provided for review. FDA contraindications include 
spinal instability, scoliosis, obesity, and osteoporosis, and have not been adequately addressed in the medical 
records. Height is 63 inches, weight is 120 pounds, and body mass index is 21.25 kg/m2. There is no 
compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception. Therefore, the requested Vertiflex Superion interspinous device at L3/4 and L4/5, 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 the Vertiflex procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Vertiflex procedure.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee would benefit from inpatient 
rehabilitation services due to their medical complexity. The Plan denied your request. The Plan says the 
enrollee's needs can be met at a lower level of care such as skilled nursing facility (SNF), home health or 
outpatient therapy. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found there are no complex nursing or rehabilitation needs. While the enrollee has a need 
for physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation 
program. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
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 would benefit from long-
term acute care due to medical complexity. The Plan denied your request. The Plan says the enrollee does not 
meet the Medicare criteria for admission to an LTACH care. The enrollee's care can be provided in the current 
inpatient hospital. 
 
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 the enrollee is receiving appropriate care at the present acute care hospital. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where the 
enrollee is currently receiving 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (G0402, G0463) provided on May 26, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are not 
payable as 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. 
 
We find that payment for CPT codes G0402 and G0463 is not supported in the medical record. Specifically, 
multiple medical visits on the same day were reported with the same revenue center, without condition code 
G0. This returns OCE edit 42, which denies the entire claim. 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 (G0402, G0463) provided on May 26, 2022.