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

 
We decided that the Plan does not have to pre-approve vitamin infusion (Infuvite) 10ml once per week. 
 
You asked the Plan to pre-approve the infusion. You say that this is medically necessary. The Plan denied your 
request. The Plan says vitamins and nutritional supplements can be taken by mouth. 
 
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 the infusion. Our reviewer says that the 
requested infusion services are not medically reasonable or necessary. Our physician reviewer found that there 
is no specific clinical rationale for IV vitamin therapy. The enrollee can tolerate oral replacement therapy. The 
review has determined that there is not any documentation that vitamins need to be taken by infusion instead of 
by mouth. 
 
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 infusion have not been met. Therefore, we decided that the Plan does not 
have to pre-approve vitamin infusion (Infuvite) 10ml once per week.
Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for code 88377-26. We decided that the Plan does not have to pay for code 
88377-TC.  
 
You asked the Plan to pay for the morphometric analysis services provided on October 4, 2022. You say that 
the documentation supports medical necessity. The Plan says that separately payment is not allowed. 
 
We decided that the Plan has to pay for code 88377-26.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
The records indicate that the specimen was taken while the enrollee was an outpatient. Per the Physician Fee 
Schedule, there is a Professional/Technical indicator of 1 for CPT code 88377. This means there is both a 
professional and technical component for the CPT code(s). In this case, an appropriate modifier to indicate the 
professional component has been billed with CPT code 88377. Based on this information, we decided that 
Medicare rules for coverage have been met. Therefore, we decided that the Plan has to pay for code 88377-26 
billed for date of service October 4, 2022. 
 
We also decided that the Plan does not have to pay for code 88377-TC. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an outpatient. Per the Physician Fee 
Schedule, there is a Professional/Technical indicator of 1 for CPT code 88377. This means there is both a 
professional and technical component for the CPT code(s). Technical components must be billed by the facility 
where the enrollee was an inpatient or outpatient and are not separately payable to the lab. Based on this 
information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the 
Plan does not have to pay for code 88377-TC billed for date of service October 4, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on October 24, 2022. 
 
You asked the Plan to pay for office visit. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for office visit provided on 
October 24, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Trivisc (J7329). 
 
You asked the Plan to pre-approve the medication. You say that the medication is medically necessary. The 
Plan denied your request. The Plan says the enrollee does not have a history of failure, contraindication, or 
intolerance to the step therapy alternatives: Synvisc, Durolane, and Gelsyn-3, and there is no information 
showing this is a continuation of therapy in the past 365 days. 
 
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 the medication. Our physician reviewer 
found the Plan requires a trial of drug(s) Synvisc, Durolane, and Gelsyn-3 before they will approve the 
requested drug, Trivisc. Based on the medical records provided there is no indication that the enrollee has tried 
and failed the required drug(s). Based on the medical records provided and the Medicare-approved major drug 
compendia there is no indication that the Plan's required drug(s) 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 the medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Trivisc (J7329).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 23020 billed for date of service April 26, 
2022. 
 
You asked the Plan to pay for procedure code 23020. The Plan denied your request. The Plan says payment for 
code 23020 is bundled into payment for code 23472. 
 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 23020 
is a column II code to column I code 23472. This claim has not been billed with an appropriate modifier to 
bypass the edit. 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 23020 billed for date of service April 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99152 provided on September 7, 2022. 
 
You asked the Plan to pay for procedure code 99152. You say that the medical records support the use of 
modifier 59 with code 99152. The Plan denied your request. The Plan says the medical records do not support 
the use of modifier 59 with code 99152. 
 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 99152 is a column II code to column I code 43239; however, 99152 
was billed with a modifier.  
 
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 procedure code 99152. Our reviewer says that the medical 
records do not support the use of modifier -59 with code 99152. Our reviewer found the procedure report 
describes esophagogastroduodenoscopy (EGD) with biopsy, with moderate sedation. In this case, moderate 
sedation was provided for EGD with biopsy. Modifier -59 is not supported, as gastrointestinal procedures 
include anesthesia. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 99152 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99152 provided on September 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ultrasound-guided radiation therapy (US-IGRT). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says daily imaging is neither necessary nor useful when treating with electron beam, 
superficial radiotherapy, or skin surface brachytherapy. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that usually IGRT is used when critical structures are abutting or in close proximity to the target that is 
being treated to high doses. This situation does not apply to this patient for which the target lesion can be seen 
on the skin to assist in daily set up. When treating skin cancers, there is generally not a need for IGRT unless 
deep structures are being treated. To bill for daily simple simulations and/or IGRT for a technology for which 
need has not been established by published data or supported by consensus guidelines (many of which 
recommend against treatment with these devices in general) is not necessary. Billing for daily IGRT which 
would not be furnished in accordance with accepted standards of medical practice."  
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve ultrasound-guided radiation therapy (US-IGRT).
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 these services are necessary for the enrollee. The 
Plan denied your request. The Plan says the denial of IRF care is correct. 
 
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. Whiel the enrollee may benefit from additional therapy, the documentation does not support that the enrollee needs this 
therapy on an intensive IRF level. 
 
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: 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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 enrollee was admitted for osteomyelitis and had a below the knee amputation.  
Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While the medical record supports a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary 
care can be provided in a different level of care. There is not a reasonable expectation that this enrollee will be 
able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Myobloc injections (rimabotulinumtoxinb) (J0587). 
 
You asked the Plan to pre-approve the medication. You say that the medication is medically necessary. The 
Plan denied your request. The Plan says the information submitted to the Plan by the enrollee's provider 
indicates the purpose of the medicine is to manage the enrollee's low back pain. The Plan states this is not one 
of the uses approved by the FDA or one of the Medicare approved pharmacy references. 
 
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 the medication. Our physician reviewer 
found the requested use of the Myobloc injections is not Food and Drug Administration-approved for the 
enrollee's diagnosis of low back pain with lumbar spondylosis. The use of Myobloc injections for the treatment 
of the enrollee's low back pain with lumbar spondylosis is not 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. The use of Myobloc injections for the treatment of the enrollee's low back pain with lumbar 
spondylosis does not meet Medicare criteria for 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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Myobloc injections (rimabotulinumtoxinb) (J0587).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an auricular stimulator. 
 
You asked the Plan to pre-approve an auricular stimulator. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that no payment may be made for the implantation of 
dorsal column or depth brain stimulators or services and supplies related to such implantation, unless certain 
conditions are met. 
 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 an auricular stimulator. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found this is considered an 
investigational/experimental procedure. Therefore, the request is deemed not medically 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 an auricular stimulator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an auricular stimulator.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on October 13, 2022. 
 
You asked the Plan to pay for the services. 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 November 14, 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 services have not been met. Therefore, 
we decided that the Plan does not have to pay for the services provided on October 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99354) provided on October 29, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is an add-on code 
and was not billed with an appropriate primary code. 
 
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 the 
services is an add-on code and has not been billed with an appropriate primary procedure code. Based on the 
claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have 
to pay for the services (99354) provided on October 29, 2022.
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 want to go to the IRF so you can regain 
maximum function and return home independently. The Plan denied your request. The Plan says the IRF 
services you are requesting do not meet the requirements for approval. 
 
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 your nursing, medical and rehabilitation needs do not require 
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical status 
does not require intensive physician and nursing oversight in an IRF. While you may benefit from additional 
multiple therapies, including physical and occupational therapy, the documentation does not reveal that you 
require or can fully tolerate this therapy on an intensive IRF level. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (G0483) provided on September 9, 2022. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed service. 
 
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 G0483 is Drug Testing, Definitive, 22 or more drug 
classes. 
 
We find that CPT code G0483 is not supported in the medical record. Specifically, the physician order 
provided does not specify testing at least 22 drug classes. 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 lab services (G0483) provided on September 9, 2022.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for the outpatient surgery. 
 
You asked the Plan to pay for the outpatient surgery. You say that the services should be covered. The Plan 
denied your request. The Plan says that the services are not covered. 
 
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. the Plan did not provided information on what services are being denied. 
Therefore, we decided that the Plan has to pay for the outpatient surgery.  
 
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.