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

 
We decided that the Plan does not have to pay for procedure codes 27606 and 28805 billed for date of service 
December 16, 2022. 
 You asked the Plan to pay for procedure codes 27606 and 28805. You say that these services were medically 
necessary. 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 claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT codes 27606 and 28805 is 1. The MAI value for these codes is 2. You billed 2 
units of each of these codes, exceeding the MUE. Specifically, you billed one line item of each code with the 
LT modifier and one line item of each code with the RT modifier instead of billing one line item per code with 
the bilateral modifier as is required. Based on this information, we decided that Medicare rules for coverage of 
procedure codes 27606 and 28805 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure codes 27606 and 28805 billed for date of service December 16, 2022.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pay for the chemotherapy administration (96413) and pembrolizumab (J9271) 
provided on September 12, 2022. 
 
You asked the Plan to pay for the chemotherapy administration and pembrolizumab. The Plan denied your 
request. The Plan says that 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 pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the chemotherapy administration and 
pembrolizumab. Our reviewer says that the documentation support that the chemotherapy administration and 
pembrolizumab were medically reasonable and necessary for the enrollee. Our physician reviewer found the 
Food and Drug Administration (FDA) has approved this for the treatment of high-risk early stage triple-
negative breast cancer, in combination with chemotherapy as neoadjuvant therapy, then continued as a single 
agent as adjuvant therapy following surgery. The enrollee is continuing as adjuvant therapy. Our reviewer also 
found that the documentation supports that the chemotherapy administration and pembrolizumab were safe and 
effective 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 chemotherapy administration and pembrolizumab have been met. Therefore, 
we decided that the Plan has to pay for the chemotherapy administration (96413) and pembrolizumab (J9271) 
provided on September 12, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (PCD) (E0675) and 
appliance (E0673) provided on July 21, 2022. 
 
You asked the Plan to pay for the PCD and appliance. The Plan denied your request. The Plan says this is not 
covered for use outside the home. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device (PCD) (E0675) and appliance (E0673) provided on July 21, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Koya Dayspring non-pneumatic compression system 
provided on September 29, 2021. 
 
You asked the Plan to pay for the Koya Dayspring non-pneumatic compression system. You say that  this 
device is not medically necessary. The Plan denied your request. The Plan says this is a Medicare-approved 
device. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the Koya Dayspring non-pneumatic 
compression system. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found that the ability to vary different aspects of 
this type of treatment has been suggested as a method of optimizing the treatment process, but there is no 
evidence to demonstrate the superiority of programmable devices compared to non-programmable devices. 
 
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 Koya Dayspring non-pneumatic compression system have not been met. 
Therefore, we decided that the Plan does not have to pay for the Koya Dayspring non-pneumatic compression 
system provided on September 29, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 12 additional physical therapy visits. 
 
You asked the Plan to pre-approve physical therapy. You say that the enrollee has improved with physical 
therapy and will lose their progress they have made if they do not continue therapy. The Plan denied your 
request. The Plan says 12 additional physical therapy visits are not medically necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 physical therapy. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found that the enrollee is stable and can continue with a home exercise 
program. The enrollee does not require a skilled therapist. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of physical therapy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve 12 additional physical therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vertiflex superion (22869, 22870). 
 
You asked the Plan to pre-approve Vertiflex superion. You say that the enrollee really needs to have this 
procedure done due to excruciating pain. The Plan denied your request. The Plan says unproven and not 
medically necessary procedures are not covered by Medicare. 
 
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 superion. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Vertiflex device is experimental and investigational for spine surgery. More 
research is needed due to insufficient evidence of efficacy. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vertiflex superion have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Vertiflex superion (22869, 22870).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for viscosupplementation injections provided from June 16, 
2022, to June 30, 2022. 
 You asked the Plan to pay for viscosupplementation injections. You say that this is supported in the records. 
The Plan denied your request. The Plan says this is experimental. 
 
The Plan follows Medicare rules. Medicare rules say that Hyaluronan preparations (viscosupplementation) for 
intra-articular injections of the knee are considered reasonable and necessary when the enrollee has failed at 
least 3 months of conservative therapy and intra-articular glucocorticoid injections. 
 
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 viscosupplementation injections. Our 
reviewer says that the requirements for coverage have not been met. Our physician reviewer found the records 
do not show that the enrollee had a trial of a knee steroid injection. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of viscosupplementation injections have not been met. Therefore, we decided that 
the Plan does not have to pay for viscosupplementation injections provided from June 16, 2022, to June 30, 
2022.
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 is stable and suitable for 
transfer to an LTACH and cannot be adequately cared for in her current condition at a skilled nursing facility 
(SNF). The Plan denied your request. The Plan says the requested LTACH admission is not medically 
necessary. 
 
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 
acute care hospital where they are currently receiving care.  There are no services available at the LTACH that the enrollee requires that are not available at the health care 
setting being offered by the Plan. The Plan has approved ongoing care in the current acute care setting. The 
requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
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: 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 this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says criteria for admission to the LTACH have not been met. 
The enrollee's medical needs are being met in the current acute setting. The LTACH would add no additional 
services. 
 
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 requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression devices (E0675 and E0673). 
 
You asked the Plan to pay for the pneumatic compression devices. You say that the items should be covered. 
The Plan denied your request. The Plan says these items are not covered.  
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. Pneumatic 
compression devices are not covered by Medicare when the place of service is an ambulatory surgical center. 
 
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, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for the pneumatic compression devices (E0675 and E0673).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for two units of procedure 92928 rendered on October 25, 2022. 
 
You asked the Plan to pay for the services. You say that the codes should be reviewed and reprocessed. The 
Plan denied your request. The Plan says procedure code 92928 is not supported by the medical records 
submitted. 
 
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 92928 is "Percutaneous transcatheter placement of 
intracoronary stent(s), with coronary angioplasty when performed; single major coronary artery or branch)." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the operative report does not 
include enough information to confirm transcatheter placement of intracoronary stent was performed. In this 
case, this procedure and units billed cannot be confirmed. 
 We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for two units of procedure 92928 rendered on October 25, 2022.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Reclast. 
 
You asked the Plan to pre-approve Reclast. You say that this drug is medically necessary. The Plan denied your 
request. The Plan says that coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Reclast. Our reviewer says that Reclast 
is medically necessary. Our physician reviewer found the record indicates that the enrollee has a diagnosis 
of osteoporosis and has undergone oophorectomy and hysterectomy. The Food and Drug Administration has 
stated that the requested drug is indicated for the prevention of osteoporosis in postmenopausal women. The 
elements of the coverage criteria are satisfied. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Reclast have been met. Therefore, we decided that the Plan has to pre-approve 
Reclast.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve medial branch blocks (64493, 64494). 
 
You asked the Plan to pre-approve medial branch blocks. You say that the requested services are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the request 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 medial branch blocks. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there is a lack of documentation of physical exam findings on the enrollee's 
lumbar facet joints. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of medial branch blocks have not been met. Therefore, we decided that the Plan 
does not have to pre-approve medial branch blocks (64493, 64494).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a replacement passenger lift up seating (E1399). 
 
You asked the Plan to pre-approve a car seat lift. You say that your health can be in jeopardy without the 
requested seat lift. You cannot be transported to appointments without a car lift. The Plan denied your request. 
The Plan says your request is not a covered benefit because your records show that this item does not meet 
Medicare's definition of DME, as it is not used to serve a medical purpose. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
 
 The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a replacement passenger lift up seating (E1399).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ozempic. 
 
You asked the Plan to pre-approve Ozempic. You say that Ozempic is medically necessary. The Plan denied 
your request. The Plan says this drug is not eligible for coverage under the Part B medical benefit. 
 
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 Ozempic.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Rituxan. 
 
You asked the Plan to pre-approve Rituxan. You say that you disagree with the Plan's 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 FDA-
approved 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 Rituxan. Our reviewer says that the 
documentation does not support that the requested drug is medically reasonable or necessary. Our physician 
reviewer found the enrollee diagnoses of other hereditary and idiopathic neuropathies and sensory 
polyneuropathy of unknown etiology with sensory ataxia. The requested use of Rituxan is not Food and Drug Administration-approved for the enrollee's diagnosis of other hereditary and idiopathic neuropathies and 
sensory polyneuropathy of unknown etiology with sensory ataxia. The use of Rituxan for treatment of other 
hereditary and idiopathic neuropathies and sensory polyneuropathy of unknown etiology with sensory ataxia is 
not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved 
medical journal. Therefore, the enrollee does 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 Rituxan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Rituxan.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Minuteman procedure. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the requested Minuteman procedure is 
considered experimental in nature, as more research is needed to support its use. The services are therefore not 
reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Minuteman procedure.