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

 
We decided that the Plan does not have to pre-approve an allograft during spine fusion surgery. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the type 
of allograft to be used has not been provided. 
 
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 requested services. Our physician 
reviewer found that the enrollee is being treated for lumbar spondylolisthesis. The Plan approved the L4-5 
laminectomy and posterior instrumented fusion. However, there is limited published, large-scale, long-term 
peer-reviewed literature that shows this requested allograft to be an effective and/or safe treatment for the noted 
pathology. Further studies are needed to demonstrate this request has beneficial outcomes compared with 
conventional treatment.  There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity 
of this request as an exception. Therefore, the requested lumbar allograft to be used in the lumbar fusion, in this 
case, 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an allograft during spine fusion surgery.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from September 14, 2022, 
through October 13, 2022. 
 
You asked the Plan to pay for the home health services. You say that an NOA was submitted in July 2022, so 
this claim is payable. The Plan denied your request. The Plan says there is no record of an NOA being received 
by the Plan for this period of care. 
 
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.  
 
 We looked at the file and Medicare rules. The provider did not submit any evidence to support that an NOA 
was sent and received by the Plan. As such, we find that the Medicare rules for coverage of these services have 
not been met. Therefore, we decided that the Plan does not have to pay for the home health services provided 
from September 14, 2022, through October 13, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like to request reconsideration of the 
denied authorization. The Plan denied your request. The Plan says the inpatient rehabilitation facility (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 documentation does not show that patient would require an intensive rehabilitation 
regimen and IRF criteria has not been met. 
 
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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee exceeds criteria for an 
LTACH admission. The Plan denied your request. The Plan says the enrollee is receiving appropriate in-patient 
acute care and does not require transfer to an LTACH. 
 
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 all medically necessary care is being provided in the current acute care setting. 
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 long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for definitive drug testing (G0482) provided on August 16, 2022. 
 
You asked the Plan to pay for drug testing. You say that these services were reported correctly. The Plan 
denied your request. The Plan says that the code used to report the services provided is not supported in the 
medical record. 
 
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 G0482 is drug test(s), definitive, 15-21 drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0482 is supported in the medical record. Specifically, the records show that drugs 
from 15 drug classes were tested in this case. Based on this information, we decided that Medicare rules for 
coverage of drug testing have been met. Therefore, we decided that the Plan has to pay for definitive drug 
testing (G0482) provided on August 16, 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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an anti-cancer regimen comprising Jemperli (J9272) and 
diphenhydramine (J1200). 
 You asked the Plan to pre-approve Jemperli and diphenhydramine. You say that the requested drug is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says step-therapy rules for coverage of the 
requested drug have not been met. 
 
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 Jemperli and diphenhydramine. Our 
reviewer says that the requested drug is not medically reasonable and necessary in this case. Our physician 
reviewer found that the Plan requires a trial of Keytruda before they will approve the requested drugs. The 
requested regimen is a new start. The provided records do not indicate that the enrollee has tried and failed the 
Plan's preferred step-one alternative. The record does not indicate that the enrollee has a contraindication to, or 
would have an adverse effect from, the Plan's preferred step-one alternative. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Jemperli and diphenhydramine have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an anti-cancer regimen comprising Jemperli (J9272) and 
diphenhydramine (J1200).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical stimulator supplies (A4595). 
 You asked the Plan to pay for the electrical stimulator supplies. You say that the item is medically necessary. 
The Plan denied your request. The Plan says the prescription within the documents submitted indicate the 
prescribing credentials are Physical Therapist which does not meet Medicares definition of a treating 
practitioner. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid physician order for the supplies provided in this case. the prescription 
within the documents submitted indicate the prescribing credentials are Physical Therapist which does not meet 
Medicares definition of a treating practitioner. Therefore, we decided that the Plan does not have to pay for the 
electrical stimulator supplies (A4595).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 37225 billed for date of service January 12, 
2022. 
 You asked the Plan to pay for procedure code 37225. 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 cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 37225 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 
procedure code 37225 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 37225 billed for date of service January 12, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital care (99291 and 99239) provided from August 6, 
2022, to August 10, 2022. 
 
You asked the Plan to pay for hospital care. You say that these services were reported appropriately. The Plan 
denied your request. The Plan says these services are not supported in the medical record. 
 
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 99291 is critical care, evaluation and management of the critically ill or critically injured patient; first 30-
74 minutes. The CPT Code Manual definition of code 99239 is hospital discharge day management; more than 
30 minutes. 
 
We find that CPT codes 99291 and 99239 are not supported in the medical record. Specifically, the medical 
records do not note the time spent providing these services. Without this information, time-based codes such as 99291 and 99239 cannot be verified. Based on this information, we decided that Medicare rules for coverage of 
hospital care have not been met. Therefore, we decided that the Plan does not have to pay for hospital care 
(99291 and 99239) provided from August 6, 2022, to August 10, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vertiflex procedure. 
 
You asked the Plan to pre-approve Vertiflex procedure. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the requested 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 Vertiflex procedure. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has chronic back pain. A magnetic resonance imaging (MRI) shows 
moderate to severe spinal stenosis at four levels. Interlaminar devices are experimental in spine surgery. 
Therefore, the enrollee does 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 Vertiflex procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Vertiflex procedure.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a single-photon emission computerized tomography 
(SPECT) scan (78452). 
 
You asked the Plan to pre-approve a SPECT scan. The Plan denied your request. The Plan says this request is 
not medically necessary because the records show the enrollee does not have evidence of an inability to 
exercise, or evidence of an uninterpretable electrocardiogram (ECG), heart failure, or heart disease. 
 
The Plan follows Medicare rules. Medicare rules say that stress testing with cardiac imaging will be considered 
medically reasonable and necessary for patients experiencing new, recurrent, or worsening cardiac symptoms, 
and new or previously unrecognized uninterpretable ECG. 
 
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 SPECT scan. Our reviewer says that a 
SPECT scan is not medically reasonable and necessary for the enrollee. Our physician reviewer found the 
enrollee has a history of hypertension and right bundle branch block on ECG, but no cardiac symptoms. There 
is no documentation that the ECG shows an uninterpretable pattern. Our reviewer found that there is no 
evidence provided that would support the need for radionuclide stress testing at this time. Our physician 
reviewer also found that in summary, there is insufficient documentation to support the medical necessity for 
the requested cardiac stress testing in this enrollee'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 SPECT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a single-photon emission computerized tomography (SPECT) scan (78452).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept basivertebral nerve ablation procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this will be helpful in managing 
enrollee's pain. The Plan denied your request. The Plan says this procedure has not been proven safe and 
effective. 
 
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 Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the medical records show that the enrollee has a compression fracture in addition to 
lumbar degeneration. The cause of the back pain is therefore unclear. As such, the requested treatment is not 
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 the Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept basivertebral nerve ablation procedure.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from September 16, 2022, 
to October 15, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the denial. The 
Plan denied your request. The Plan says the claim has not been billed with the correct admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from September 16, 2022, to 
October 15, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from February 13, 2022, 
to March 14, 2022.  
You asked the Plan to pay for the home health services as billed. You say that you submitted the required 
NOA. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from February 13, 2022, to 
March 14, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A0425 billed for date of service November 6, 
2022. 
 
You asked the Plan to pay for procedure code A0425. You say that these services were necessary and are 
supported in the medical record. The Plan denied your request. The Plan says the number of units billed 
exceeds the maximum allowed per line. 
 The Plan must follow Medicare rules. Medicare rules say that claim lines submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 1. If a code has an MAI of 1, appropriate use of 
a modifier may be used to report the same code on separate lines of the claim, and each line for that code will 
be separately evaluated against the MUE value for that code. 
 
In this case, the MUE for CPT code A0425 is 250. The MAI value for this code is 1. You billed 324 units of 
this code on a single line, exceeding the MUE. Based on this information, we decided that Medicare rules for 
coverage of procedure code A0425 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code A0425 billed for date of service November 6, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for DecisionDx-SCC testing (0315U) provided on September 
30, 2022. 
 
You asked the Plan to pay for DecisionDx-SCC testing. You say that this test was medically necessary. The 
Plan denied your request. The Plan says this test is not covered by the MolDX program. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. Once this is complete, the test is assigned a 
reimbursement rate and a unique test identifier. We looked at the file and Medicare rules. This test is listed in the DEX database as non-covered. This 
determination was made and is specific to the test at issue. Based on this information, we decided that 
Medicare rules for coverage of DecisionDx-SCC testing have not been met. Therefore, we decided that the 
Plan does not have to pay for DecisionDx-SCC testing (0315U) provided on September 30, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 86077 billed for date of service September 
21, 2022. 
 You asked the Plan to pay for procedure code 86077. You say that the medical records support the additional 
unit of service. 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 cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 86077 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 
procedure code 86077 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 86077 billed for date of service September 21, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMs Heart Failure system. 
 
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 that the CardioMEMs was approved by 
the Food and Drug Administration (FDA) in 2014. Nonetheless, there remains a dearth of randomized, blinded 
clinical studies examining long-term clinical outcomes establishing the value of CardioMEMS in patient 
management. As a result, at this time the CardioMEMS system would not be considered medically appropriate 
and necessary in the enrollee'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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a CardioMEMs Heart Failure system.