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

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) coded as 82728, 83540, 83550 provided on June 21, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that at this time, there is no 
contractual agreement which indicates that these tests should be included in the dialysis rate. The Plan denied 
your request. The Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) coded as 82728, 
83540, 83550 provided on June 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that without the requested home ventilator, the 
enrollee is high risk for hospital readmission and potentially life-threatening exacerbation. You say that it is in 
the best interest of the enrollee to approve the requested equipment immediately. The Plan denied your request. 
The Plan says the requested home ventilator will be set in average volume-assured pressure support (AVAPS) 
mode with Auto-EPAP (AE) that could be delivered by bilevel positive airway pressure (BiPAP.) 
 
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 criteria for coverage have not been met. Our physician reviewer found a home ventilator is not 
medically necessary. The enrollee has a diagnosis of chronic obstructive pulmonary disease (COPD), although there are no pulmonary function tests to confirm.  There is a history of obstructive sleep apnea (OSA) with 
intolerance to BiPAP, although details are not provided.  Arterial blood gasses (ABGs) during recent 
hospitalization are consistent with acute on chronic hypercarbic respiratory failure, but there is no ABG done 
while stable to confirm chronic carbon dioxide (CO2) retention.  If there is chronic CO2 retention, the enrollee 
may benefit from BiPAP with AVAPS during sleep.  This has not been tried and failed as an outpatient.  
Intolerance of BiPAP is usually related to mask/interface issues and does not represent BiPAP failure. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prochlorperazine. 
 
You asked the Plan to pre-approve prochlorperazine. You say that the enrollee needs this. The Plan denied your 
request. The Plan says the requested drug is considered self-administered. The Plan says self-administered 
drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the requested drug is not 
covered under Medicare Part B. 
 
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 prochlorperazine.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Synvisc-One injection (J7325). 
 
You asked the Plan to pre-approve a Synvisc-One injection. The Plan denied your request. The Plan says the 
enrollee does not meet the criteria for coverage. The Plan also says that specifically, the enrollee reported a bad 
reaction to the previous Synvisc injection in March 2021, and because of this, a second injection of the same 
likeness is unwarranted. 
 
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 a Synvisc-One injection. Our reviewer 
says that a Synvisc-One injection is not reasonable or necessary for the enrollee. Our physician reviewer found 
the record indicates that the enrollee has a diagnosis of osteoarthritis of the knee. The record indicates that the 
enrollee had a previous viscosupplementation injection with Synvisc-one and did not achieve benefit. Our 
reviewer found that the FDA has not stated that the requested drug is indicated for the enrollee's condition. The 
Medicare approved drug compendia do not contain a supportive citation for the use of the requested drug in the 
enrollee's clinical situation. Our physician reviewer also found that the elements of the coverage criteria are not 
satisfied, and the requested service cannot be recommended. 
 
 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 Synvisc-One injection have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Synvisc-One injection (J7325).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the audio evoked potentials interpretation and report 
rendered on January 19, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that modifier -26 cannot be used with codes with a 
PC/TC indicator of 0. 
 
We looked at the file and Medicare rules. Billed procedure code 92653 has a PC/TC indicator of 0 and was 
billed with the -26 modifier. 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 pay for the audio evoked 
potentials interpretation and report rendered on January 19, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Pembrolizumab, Carboplatin, Pemetrexed and 
Aprepitant. 
 
You asked the Plan to pre-approve Pembrolizumab, Carboplatin, Pemetrexed and Aprepitant. You say that the 
clinical documentation provided supports that the requested drugs are medically necessary and appropriate. The 
Plan denied your request. The Plan says because the enrollee was experiencing disease progression on 
Prembrolizumab, the drug regimen being requested is not supported. 
 
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 Pembrolizumab, Carboplatin, 
Pemetrexed and Aprepitant. Our reviewer says that the criteria for coverage have not been met. Our physician 
reviewer found the use of the requested drug regimen is listed as not indicate by the compendia. The duration 
of treatment of adults with non-small-cell lung carcinoma (NSCLC) with Pembrolizumab is until disease 
progression, or there is unacceptable toxicity, or up to 24-months. In this case, there has been disease progression while being treated with Pembrolizumab. The requested drug regimen is not considered safe and 
effective and otherwise reasonable and 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 Pembrolizumab, Carboplatin, Pemetrexed and Aprepitant have not been met. 
Therefore, we decided that the Plan does not have to pre-approve Pembrolizumab, Carboplatin, Pemetrexed 
and Aprepitant.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a special long-term heart monitor. 
 
You asked the Plan to pre-approve a special long-term heart monitor. You say that the requested heart monitor 
is medically necessary. The Plan denied your request. The Plan says there is no documentation that the enrollee 
had a previous non-diagnostic trial of external ambulatory cardiac event monitoring of not less than 14 
continuous days. The Plan says that they cannot say that the implantable cardiac event monitor is reasonable 
and necessary at this time. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a special long-term heart monitor. Our 
reviewer says that a special long-term heart monitor is not considered medically reasonable and necessary in 
this case. Our physician reviewer found the enrollee had no history of atrial fibrillation, nor were any 
significant cardiac arrhythmias noted on electrocardiogram (ECG) monitoring. A recent randomized clinical 
trial found that continuous monitoring for atrial fibrillation with an implantable loop recorder (ILR), followed 
by treatment with oral anticoagulation if atrial fibrillation was detected, was not superior to usual care in 
reducing stroke or systemic embolism among patients at high risk of stroke but without a known prior history of atrial fibrillation. At this time, insertion of an ILR would not be considered medically appropriate and 
necessary in this patient's 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 a special long-term heart monitor have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a special long-term heart monitor.
Appeal type: Hospice
Decision: Favorable

 
We decided that the Plan has to pay for home health services provided from February 1, 2022, to 
February 20, 2022. 
 
You asked the Plan to pay for home health services. You say that that the primary diagnosis as billable is 
payable. The Plan denied your request. The Plan says that at the time the services were rendered, the member 
was under hospice. 
 
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. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not provided us with proof of hospice enrollment. 
Therefore, we decided that the Plan has to pay for home health services provided from February 1, 2022, to 
February 20, 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided May 5, 2022, to June 3, 
2022. 
 
You asked the Plan to pay for the home health services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says an NOA is required to process the claim. 
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is May 5, 2022. The NOA submitted has a "from" date of May 5, 2022. 
However, the claim was submitted with an admit date of January 3, 2022. As the NOA submitted was 
incorrect, no payment can be made on this claim. Therefore, we decided that the Plan does not have to pay for 
the home health services provided May 5, 2022, to June 3, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve an injection procedure for sacroiliac (SI) joint (27096). 
 
You asked the Plan to pre-approve the injection. You say that the enrollee is in great pain. You also say they 
have tried other forms of therapies, treatments, and medications with no success. The Plan denied your request. 
The Plan says that 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 the injection. Our reviewer says that the 
requested injection is considered medically reasonable and necessary in this case. Our physician reviewer 
found a successful block and therapy is defined as 50% pain relief for three months. The reviewer found that 
the provided documentation supports this success. Therefore, the reviewer found that the requested injection is 
medically necessary in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the injection have not been met. Therefore, we decided that the Plan has to pre-
approve an injection procedure for sacroiliac (SI) joint (27096).  
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing home services (G0299x30), in home 
physical therapy (G0151x15) and in home occupational therapy (G0152x15) to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve home health services. You say that you disagree with the denial. The Plan 
denied your request. The Plan says you must use network providers to get your medical care and services. 
These services are available by a provider in your network. 
 
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. 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. Therefore, we decided that the Plan does not have to pre-approve 
skilled nursing home services (G0299x30), in home physical therapy (G0151x15) and in home occupational 
therapy (G0152x15) to be provided by an out-of-network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital discharge day management services provided on 
April 13, 2022. 
 
You asked the Plan to pay for the hospital discharge day management services. You say that you disagree with 
the Plan's denial. The Plan denied your request. The Plan says the enrollee was enrolled in hospice for this date 
of service.  
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the hospital discharge day management services provided on 
April 13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an orthosis (L4361) provided on June 8, 2022. 
 
You asked the Plan to pay for the orthosis. You say that this item was medically necessary. The Plan denied 
your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that for orthoses, claim lines billed with codes 
without a KX, GA, or GZ modifier will be rejected as missing information. 
 
We looked at the file and Medicare rules. The claim was not billed with the required KX modifier. Based on 
this information, we decided that Medicare rules for coverage of the orthosis have not been met. Therefore, we 
decided that the Plan does not have to pay for an orthosis (L4361) provided on June 8, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the cervical spine 
(72141) and magnetic resonance imaging (MRI) of the brain (70553). 
 
You asked the Plan to pre-approve these services. You say that the requested services are medically necessary 
for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of 
the requested services. 
 
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 these services. Our reviewer says that 
the requested services are not medically necessary. Our physician reviewer found that in this case, the record 
indicates that the enrollee has migraine headaches and myalgia. The record does not indicate that the enrollee 
had an abnormal neurological examination or any red flag symptoms. The record does not indicate that the 
enrollee has tried and failed medical treatment for the associated conditions and that these therapies have just 
been initiated. The record does not indicate how the requested tests will alter management of the enrollee's 
conditions. The requested services are not medically necessary and reasonable for the diagnosis and treatment 
for the enrollee's clinical condition at this time. The elements of the coverage criteria are not satisfied. The 
requested services cannot be recommended. 
 
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 magnetic resonance imaging (MRI) of the 
cervical spine (72141) and magnetic resonance imaging (MRI) of the brain (70553).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the respiratory pathogen panel (87632, 87503 and 87634) 
billed for date of service March 2, 2022. 
 
You asked the Plan to pay for the laboratory panel. You say that this test was necessary and is supported as 
billed. The Plan denied your request. The Plan says this panel was not reported in accordance with Medicare 
billing guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that a respiratory pathogen panel test is a single 
service with a single unit of service (UOS=1). A respiratory pathogen panel test must not be unbundled and 
billed as individual components regardless of the fact that the panel reports multiple individual pathogens and/or targets. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory panel have not been met. Specifically, this respiratory pathogen panel was 
unbundled and billed with multiple procedure codes. Therefore, we decided that the Plan does not have to pay 
for the respiratory pathogen panel (87632, 87503 and 87634) billed for date of service March 2, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of interlaminar/interspinous process 
stabilization/distraction device. 
 
You asked the Plan to pre-approve insertion of interlaminar/interspinous process stabilization/distraction 
device. You say that your spinal surgeon says that you need the surgery to be done. The Plan denied your 
request. The Plan says the requested services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that LADR is non-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 insertion of interlaminar/interspinous 
process stabilization/distraction device. Our reviewer says that the documentation does not support that the 
requested services are medically reasonable or necessary. Our physician reviewer found that you have back 
pain. Interlaminar distraction devices are considered experimental. More research is needed. Therefore, you do 
not meet criteria for the requested 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 insertion of interlaminar/interspinous process stabilization/distraction device 
have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of 
interlaminar/interspinous process stabilization/distraction device.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services rendered on April 21, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 21016 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 21016 is radical resection of tumor (eg, sarcoma), soft 
tissue of face or scalp; 2 cm or greater. 
 
We find that CPT code 21016 is not supported in the medical record. Specifically, there is no documentation of 
a radical resection of a soft tissue tumor from the face or scalp of 2 centimeters or greater. 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 pay for the surgical services rendered on April 21, 2022.