Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drugs provided on May 18, 2022. 
 
You asked the Plan to pay for the drugs. The Plan denied your request. The Plan says self-administered drugs 
are not covered in the outpatient setting. 
 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 pay for the drugs provided on May 18, 
2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the three dimensional (3D) rendering with interpretation and 
reporting (76376) provided on September 2, 2022. 
 
You asked the Plan to pay for the 3D rendering with interpretation and reporting. You say that the enrollee had 
multiple exams on this date of service, and you would like this claim to be reconsidered for processing. The 
Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim and was correctly 
denied. 
 The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on October 26, 2022. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for the 3D rendering with interpretation and 
reporting have not been met. Therefore, we decided that the Plan does not have to pay for the three dimensional 
(3D) rendering with interpretation and reporting (76376) provided on September 2, 2022.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pay for the Nanoparticle Albumin-Bound Paclitaxel (NAB-Paclitaxel) (codes 
J9264 and J9264-JW) and outpatient surgery services provided on November 11, 2022. 
 
You asked the Plan to pay for the NAB-Paclitaxel and outpatient surgery services. You say that Paclitaxel, 
Albumin-Bound is medically necessary for the treatment of recurrent metastatic disease. You also say that you 
believe you treated the enrollee in good faith and made the best medical decision according to their presenting 
symptoms at the time. The Plan denied your request. The Plan says that this service does not meet the coverage 
requirements in the applicable Local Coverage Determination (LCD) or National Coverage Determination 
(NCD). The Plan also says charges for or in connection with services or supplies that are, as determined by the 
Plan, considered to be experimental or investigational are excluded from coverage under the enrollee's plan. 
 
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 NAB-Paclitaxel and outpatient surgery 
services. Our reviewer says that the NAB-Paclitaxel and outpatient surgery services were medically reasonable 
and necessary for the enrollee. Our physician reviewer found the requested use of NAB-Paclitaxel is not FDA-
approved for the enrollees diagnosis. The use is supported by one of the major drug compendia or by clinical 
research that appears in a Centers for Medicare & Medicaid Services (CMS) approved medical journal. Our 
reviewer found that the use is not listed as not indicated, not supported or not recommended in any of the 
compendia. Our physician reviewer also found that the documentation does support that the requested drug is 
safe and effective and otherwise reasonable and necessary 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 the NAB-Paclitaxel and outpatient surgery services have been met. Therefore, 
we decided that the Plan has to pay for the Nanoparticle Albumin-Bound Paclitaxel (NAB-Paclitaxel) (codes 
J9264 and J9264-JW) and outpatient surgery services provided on November 11, 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 pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee risks re-hospitalization and falls without 
IRF services. The Plan denied your request. The Plan says the request is not medically necessary. 
 
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 that the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Qsymia. 
 
You asked the Plan to pre-approve Qsymia. You say that the medication is necessary. The Plan denied your 
request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 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 Qsymia.  
 
Benefits for Qsymia 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that admission will lessen your chances of being 
admitted back to the Hospital with being a 6.5 oxygen level a discharge to home is not safe. The Plan denied 
your request. The Plan says your records do not show to require daily skilled services that can be provided only 
on an inpatient basis in a skilled nursing facility, services you require can safely be received at a different 
setting, home with home health, in residential care, or home with close follow-up with your doctor. 
 
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 you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (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 skilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous vertebroplasty. 
 
You asked the Plan to pre-approve percutaneous vertebroplasty. You say that the enrollee has experienced a 
decrease in mobility and overall quality of life. You say the enrollee would like to proceed with the surgery for 
pain relief and to return to normal physical activities. The Plan denied your request. The Plan says the criteria is 
not met for the requested procedure. 
 
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 percutaneous vertebroplasty. Our 
reviewer says that the requested service is not considered medically reasonable and necessary in this case. 
Our physician reviewer found cement augmentation of the sacrum for insufficiency fracture 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 percutaneous vertebroplasty have not been met. Therefore, we decided that the 
Plan does not have to pre-approve percutaneous vertebroplasty.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Barostim Neo system (0266T, C1825). 
 
You asked the Plan to pre-approve the surgical procedure. You say that you are submitting this request for 
redetermination of the enrollee's implantation of a carotid sinus baroreflex system for heart failure. The Plan 
denied your request. The Plan says the clinical value and effectiveness of the Barostim Neo System in the 
setting of congestive heart failure 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 the surgical procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Baroreflex stimulation devices have been considered potential alternative 
treatments for resistant hypertension and heart failure. The Barostim Neo system is an electronic pulse generator implanted underneath the clavicle with a lead tunneled under the skin to the carotid sinus in the neck. 
The pulse generator delivers electrical impulses, analogous to a cardiac pacemaker, to the baroreceptors of one 
of the carotid arteries. In August 2019, the Food and Drug Administration (FDA) approved the system for use 
in patients with refractory heart failure who remain symptomatic despite treatment with guideline-directed 
medical therapy, are New York Heart Association (NYHA) Class III, have an ejection fraction less than 35%, 
and are not candidates for bi-ventricular pacing. This was based on a clinical study demonstrating improvement 
in normal daily activities, distance walked, quality of life, and improved cardiac levels biomarker levels. There 
remains an absence of randomized, blinded clinical studies examining long-term clinical outcomes establishing 
the value of Barostim Neo in patient management. As a result, at this time the Barostim Neo system would not 
be considered medically reasonable and necessary in this enrollees 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 the surgical procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Barostim Neo system (0266T, C1825).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient services provided on June 14, 2022. 
 
You asked the Plan to pay for the outpatient services. The Plan denied your request. The Plan says this claim is 
not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that effective for claims with dates of service July 1, 
2007 and after, the non-Outpatient Prospective Payment System (OPPS) Outpatient Code Editor (OCE) will be 
integrated into the OPPS OCE. 
 
We looked at the file and Medicare rules. In this case, code 27487 was billed on the claim. This is an "inpatient 
only" procedure. As such, this returned edit 49 was the claim was routed through the OCE. This edit denies all 
claim lines on this claim. A corrected claim is needed for payment to be considered. Based on this information, we decided that Medicare rules for coverage of the outpatient services have not been met. Therefore, we 
decided that the Plan does not have to pay for the outpatient services provided on June 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87789 and 87481 billed for date of service 
September 28, 2022. 
 You asked the Plan to pay for procedure codes 87789 and 87481. The Plan denied your request. The Plan says 
payment for codes 87789 and 87481 is bundled into payment for code 87150. 
 
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 codes 
87789 and 87481 are column II codes to column I code 87150. 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 codes 87789 
and 87481 billed for date of service September 28, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs to be assessed both medically and 
functionally in regard to their premorbid functional capacity to determine whether to benefit from a 
rehabilitation level of care offered by mentioned facility. The Plan denied your request. The Plan says the 
enrollee's records do not show that you need an intensive team for your care, services needed can be provided 
safely in other settings, at a skilled nursing facility, home with home health services or home with 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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positive airway pressure (PAP) device (E0601). 
 You asked the Plan to pre-approve a PAP device. You say that the item is medically necessary. The Plan 
denied your request. The Plan says you have not used the PAP device for greater than or equal to 4 hours per 
night on 70% of nights during a consecutive thirty (30) day period. 
 
The Plan must follow Medicare rules. Medicare rules say that adherence to therapy is defined as use of PAP 
greater than or equal to 4 hours per night on 70% of nights during a consecutive thirty (30) day period anytime 
during the first three (3) months of initial usage. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a PAP device have not been met. Therefore, we decided that the Plan does not have to pre-approve 
a positive airway pressure (PAP) device (E0601).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says the information we 
have about your condition the enrollee does not meet all the requirements, services may be safely provided in 
an alternative setting, at a skilled nursing facility, outpatient setting or home health care. 
 
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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the item is medically necessary. The Plan 
denied your request. The Plan says the item is not medically necessary. 
 
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 member does not need this item. Our physician reviewer found provided records document that the 
home ventilator is being requested for use in average volume assured pressure support (AVAPS) mode with 
auto-EPAP (AE) which could be provided by a BiPAP device with AVAPS and a back-up rate. 
 
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 (E0466).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the LTACH can render services that will 
improve the enrollee's condition and avoid unnecessary hospital readmissions. The Plan denied your request. 
The Plan says the LTACH is not medically necessary, and the enrollee's needs are being met in the current 
hospital 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. Our 
physician reviewer found the enrollee was admitted with acute respiratory failure in the setting of multiple rib 
fractures following motor vehicle crash. The record indicates that the enrollee is improving but still has acute medical issues that require acute care services before transitioning to a lower level of care. The enrollee 
continues to receive acute care services, and these have not been denied. The medical record does not indicate 
that the enrollee requires services that they are not currently receiving but that would be available at the 
LTACH facility. 
 
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.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injections provided on November 8, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for injections. You say that this service is supported in the records. The Plan denied 
your request. The Plan says this was 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 injections provided on November 8, 2022, by an 
out-of-network (OON) provider.