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

 
We decided that the Plan does not have to pre-approve ipilimumab injection (CPT code J9228) and nivolumab 
(CPT code J9299). 
 
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 has already received another drug, Pembrolizumab, which 
works in the same way to treat their cancer. The Plan states unfortunately, medical records provided by the 
enrollee's doctor indicate that their condition worsened while taking Pembrolizumab. The Plan states there is no 
safety evidence or clinical data that nivolumab and ipilimumab work once the disease has grown after 
previously receiving Pembrolizumab. 
 
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 the medication. Our physician reviewer 
found the requested use of ipilimumab injection (CPT code J9228) and nivolumab (CPT code J9299) is not 
FDA-approved for the enrollees diagnosis; furthermore, approval is for first line and this enrollee has 
progression of disease on prior immunotherapy.  The use is not supported by one of the major drug compendia or by clinical research that appears in a CMS-
approved medical journal. 
 
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 ipilimumab injection (CPT code J9228) and nivolumab (CPT code J9299).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of a interlaminar/interspinous spinal 
stabilization device for the enrollee. 
 
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied 
your request. The Plan says there are many levels of severe spinal stenosis. 
 
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 procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found current evidence based medical guideline and peer reviewed literature do not fully support the 
spinal decompression device procedure over the gold standard of lumbar laminectomy. There is a lack of 
large volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollees 
medical condition. FDA indications include implantation of the Superion device at one or two adjacent lumbar 
levels in patients with moderate spinal stenosis in whom operative treatment is indicated at no more than two 
levels, from L1 to L5. This enrollee has multiple degrees of spinal stenosis, many not at FDA indicated levels 
of moderate spinal stenosis (including the planned level of implantation at L2-3 and L3-4.). FDA contraindications include spinal instability, scoliosis, obesity, and osteoporosis (which have not been 
adequately addressed in the medical records.) There is imaging evidence of right lateral listhesis of L4 relative 
to L5 and left lateral listhesis of L2 relative to L3, with no discussion of spinal instability on flexion/extension 
films. His height is 71 inches, weight is 190.4 pounds, and body mass index is 26.65 kg/m2. There is imaging 
evidence of apex-right curvature of the lumbar spine centered at L3, with no documentation of the Cobb angle. 
There is no discussion indicating that a DEXA scan has demonstrated the lack of significant osteoporosis in 
this patient. There is no compelling rationale presented or extenuating circumstances noted to support the 
medical necessity of this request as an exception. Therefore, the request for Vertiflex Superion Interspinous 
device at L2-3 and L3-4 is not medically reasonable or necessary.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve insertion of a interlaminar/interspinous spinal stabilization device for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cardiac device monitoring (93280) provided on January 29, 
2021 to September 14, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the cardiac monitoring services. You say that the primary provider MIA. You 
finally got a letter from him in September that he had closed his practice. The Plan denied your request. The 
Plan says enrollees must receive their medical services from an in-network provider with the exception being 
urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization 
before services being rendered. 
 
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 cardiac device monitoring (93280) provided on 
January 29, 2021 to September 14, 2021 by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xifaxan 550MG tablet. 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says Xifaxan is a self-administered drug and does not fall under Part B 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 Xifaxan 550MG tablet.  
 Benefits for the medication 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve injection(s), diagnostic or therapeutic agent, 
paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or 
CT), lumbar or sacral; single level (CPT code 64493) and second level (CPT code 64494). 
 
You asked the Plan to pre-approve the services. You say that the enrollee is in severe pain. The Plan denied 
your request. The Plan says the Medicare criteria for reasonable and necessary are not met because 
radiofrequency ablation and pulsed radiofrequency for treatment of acute, subacute, or chronic sacroiliac (SI) 
joint pain are considered experimental, investigational, or unproven due to insufficient evidence in the peer 
reviewed literature, this procedure has not been shown to be safe and effective in long term studies. 
 
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 items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this is considered experimental/ investigational because of the wide variation in efficacy 
reported in the peer reviewed literature. Therefore, the request is deemed not medically reasonable or 
necessary. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or 
nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; single level (CPT 
code 64493) and second level (CPT code 64494).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance transportation services (A0426, A0425) provided 
on October 21, 2021. 
 
You asked the Plan to pay for ambulance services. You say that these services were necessary and were billed 
appropriately. The Plan denied your request. The Plan says the enrollee was inpatient status at the same facility 
from October 19, 2021, to November 2, 2021. Because the enrollee was inpatient on the date in question, the 
payment for these services is bundled into the payment to the facility under the hospital prospective payment 
system. 
 
Medicare rules say that patient transportation is covered as an inpatient hospital, CAH or SNF service and is 
payable under Part A. This means that the service cannot be classified and paid for as an ambulance service 
under Part B. 
 
We find that the ambulance transportation in this case is not eligible for separate payment. The documentation 
shows that the enrollee was inpatient at one facility on the date in question and this transport is therefore 
considered patient transport and covered under Part A with the hospital payment. Based on this information, we 
decided that Medicare rules for coverage of ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for ambulance transportation services (A0426, A0425) provided on October 21, 
2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound, breast, unilateral (76642RT) provided on 
September 2, 2021. 
 
You asked the Plan to pay for the ultrasound. You say that the enrollee had multiple exams on this date of 
service. You also say that the claim should be paid. The Plan denied your request. The Plan says the claim 
processed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the ultrasound, breast, unilateral (76642RT) provided on September 2, 2021. have been met. Specifically, the record shows that the Plan 
processed and paid one unit of procedure code 76642RT. The documentation submitted does not support that 
an additional unit of procedure code 76442RT was rendered on the billed date of service. Therefore, we 
decided that the Plan does not have to pay for the ultrasound, breast, unilateral (76642RT) provided on 
September 2, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan of the head or brain 
(70450) provided on February 15, 2022. 
 
You asked the Plan to pay for the CT scan services. You say that you would like this claim reprocessed as it 
denied as a duplicate in error. The Plan denied your request. The Plan says this claim was not billed with an 
appropriate modifier as required by Medicare rules. 
 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 70450 
is a column II code to column I code 70496. 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 the computed tomography (CT) scan of the head or brain (70450) 
provided on February 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on September 22, 2021. 
 
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 separately payable. 
 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 87651 
and 87150 are column II codes to column I code 87801. 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 the laboratory services rendered on September 22, 
2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mammography services provided on April 12, 2021. 
 
You asked the Plan to pay for the services provided. You say that you are the radiology providers who reads for 
the images taken. The Plan denied your request. The Plan says the rule for payment has not been met. 
 The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 77065 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the 
services provided have not been met. Therefore, we decided that the Plan does not have to pay for the 
mammography services provided on April 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on February 24, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the services rendered are not a covered benefit. 
 
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 the office visit provided on February 24, 2022 by 
an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on May 25, 2021. 
 
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 claim was processed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that when services or supplies are rendered by a non-
contracting, original Medicare, participating provider, there is no balance billing paid by either the plan or the 
enrollee.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of these services have not been met. Specifically, the record indicates that the Plan has paid the 
Medicare Allowed Amount for this service. A Medicare provider should accept the Medicare Allowed Amount 
as payment in full. In this case, the Plan is not responsible for paying the balance that remains after the 
Medicare allowed payment. Therefore, we decided that the Plan does not have to pay for the laboratory 
services rendered on May 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CGM system (Dexcom G6) and supplies. 
 
You asked the Plan to pre-approve the CGM and supplies. You say that the CGM and supplies are necessary. 
The Plan denied your request. The Plan says the Medicare rules have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 
 
 
 We looked at the file and Medicare rules. The clinical information provided does not show that the enrollee 
takes insulin at least three times or more per day or uses a continuous subcutaneous insulin infusion pump. 
Based on this information, we decided that Medicare rules for coverage of the CGM and supplies have not been 
met. Therefore, we decided that the Plan does not have to pre-approve the CGM system (Dexcom G6) and 
supplies.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home health skilled nursing services (PT) code 
G0299 x 5). 
 
You asked the Plan to pre-approve the home health skilled nursing services. You say that the services are 
necessary. The Plan denied your request. The Plan says the enrollee's records do not support the need for a 
skilled nurse to make more visits. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 
 
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 home health skilled nursing 
services. Our physician reviewer found the documentation does not support that the enrollee requires additional 
skilled nursing services to provide treatment that is medically necessary. The enrollee does not require 
additional skilled nursing services to effectively provide treatment, care, and/or services in order to improve the 
enrollees condition, perform a maintenance program to maintain the enrollees condition and/or prevent 
deterioration. The enrollee has been medically stable without any recent exacerbations of chronic medical 
problems or hospitalizations. The requested home health services are not 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 the home health skilled nursing services have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the home health skilled nursing services (PT) code G0299 x 
5).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided on December 30, 
2021, to January 28, 2022. 
 You asked the Plan to pay for SNF care. You say that the services at issue are coverable under Medicare. The 
Plan denied your request. The Plan says medical necessity rules for SNF care have not been met. 
 
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 pay for SNF care. Our reviewer says that the SNF 
care at issue is not medically reasonable and necessary in this case. Our physician reviewer found that, based 
on the medical records provided, there is no documentation that the enrollee required skilled nursing services, 
that is, the specialized skill, knowledge and judgment of a skilled professional nurse were not required to safely 
and effectively provide medically necessary and reasonable treatment from December 30, 2021, through 
January 28, 2022. The available records did not document the need for intravenous medications, new tube 
feeding or ostomy care, or daily complex wound care. The enrollee did require skilled therapy services, that is, 
the specialized skill, knowledge and judgment of a qualified therapist were required to safely and effectively 
provide medically necessary and reasonable treatment. However, daily skilled services were not required. The 
patient was walking household distances with a rolling walker with contact guard assistance and was contact 
guard assist for transfers. Services in the nursing facility appear custodial 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for skilled nursing facility (SNF) care provided on December 30, 2021, to January 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the breast cyst surgery, diagnostic and laboratory services 
provided March 3, 2021 to March 29, 2021 while outside of the Unites States. 
 
You asked the Plan to pay for the surgical, diagnostic and laboratory procedures. You say that you were in 
Colombia since December 7, 2020. You took a provisional health insurance, having the opportunity to take the 
surgery on March 8, 2021. It was an ambulatory procedure, and you request reimbursement of $1,134 for this 
mandatory surgery. The Plan denied your request. The Plan says elective procedures outside of the US is not 
covered by Medicare or the Plan unless it is emergency/urgent care. 
 
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that 
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and 
pre-approved care.    
We looked at the file, and Medicare rules. The records show that this was an elective surgical procedure. Based 
on this information, we decided that Medicare rules for coverage of the surgical, diagnostic and laboratory 
procedures have not been met. Therefore, we decided that the Plan does not have to pay for the breast cyst 
surgery, diagnostic and laboratory services provided March 3, 2021 to March 29, 2021 while outside of the 
Unites States.