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

 
We decided that the Plan does not have to pre-approve Opdualag. 
 
You asked the Plan to pre-approve Opdualag. You say that this drug is medically reasonable and necessary for 
the enrollee's condition. The Plan denied your request. The Plan says this drug can only be given as initial (first 
line) treatment for skin cancer. 
 
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 Opdualag. Our reviewer says that the 
requested drug is not medically reasonable and necessary for the enrollee's condition. Our physician reviewer 
found the enrollee has been diagnosed with metastatic melanoma and has been treated with previous lines of 
chemotherapy drugs. In this case, the use of Opdualag is not FDA-approved for the enrollees diagnosis with 
progression of disease on prior immunotherapies. Furthermore, the use of this drug is not supported by one of 
the major drug compendia or by clinical research that appears in a Medicare-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 Opdualag have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Opdualag.
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 this device is medically necessary. The Plan 
denied your request. The Plan says the criteria for coverage have not been met. 
 
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 requested home ventilator is not medically reasonable and necessary. Our physician reviewer found 
that you have COPD and a history of lung cancer. You were recently hospitalized with acute on chronic 
hypoxic and hypercarbic respiratory failure, likely due to a combination of COPD exacerbation and complete 
atelectasis of the left lung due to mucous plugging and prior radiation fibrosis. There may also be an element of 
obesity hypoventilation syndrome.  You may benefit from ventilator support during sleep, for example bi-level positive airway pressure (BiPAP) 
with average volume-assured pressure support.  But Medicare does not cover a home ventilator when used as 
BiPAP. There is no demonstrated failure of BiPAP. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to further pay for the eye surgery services provided on September 17, 
2021. 
 
You asked the Plan to further pay for the eye surgery services. You say that you would like to be reimbursed 
the amount you paid for this service. The Plan denied your request. The Plan says the cost share has processed 
correctly in this case. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 40% 
coinsurance for surgery services performed by an out-of-network provider.  
 
You have been asked to pay a total cost share of $347.64 for the eye surgery services ($869.10 Medicare-
allowed amount x 40% coinsurance). This service falls within the surgery services performed by an out-of-
network provider benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan.  This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to further pay for the eye surgery services provided on September 17, 2021.  
 
Of note, you will need to go back to your provider regarding the charged amount of $4700 and the Medicare-
allowed amount of $869.10 if you believe you are being balanced billed. The Plan has met their contractual 
obligation regarding what payment they are responsible for.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6530. 
 
You asked the Plan to pre-approve the compression stockings. You say that the stockings are medically 
necessary. The Plan denied your request. The Plan says this type of dressing is non-covered. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6530.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laminectomy (63012) and spinal cord decompression 
(63056) provided on September 29, 2021. 
  You asked the Plan to pay for the laminectomy (63012) and spinal cord decompression (63056). You say that 
the denial for the billed CPT codes as inclusive is incorrect as they are separately payable with an appropriate 
modifier. You say that the attached documents justify the billing, and the claim should be processed for 
payment. The Plan denied your request. The Plan says procedure code 63012 is considered inclusive to 
procedure code 22633 and procedure code 63056 is considered inclusive to procedure code 22634. 
 
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 63012 is a column II code to column I code 22633, and code 63056 is 
a column II code to column I code 22634; however, 63012 and 63056 were 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 the laminectomy (63012) and spinal cord decompression 
(63056). Our reviewer says that the documentation submitted was reviewed and does not meet the criteria for 
coverage. Our reviewer found that CPT codes 63012 and 63056 are considered inclusive to 22633 and 22634 
as the procedures were performed at the same level. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the laminectomy (63012) and spinal cord decompression (63056) have not been 
met. Therefore, we decided that the Plan does not have to pay for the laminectomy (63012) and spinal cord 
decompression (63056) provided on September 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Negative pressure wound therapy electrical pump 
(NPWT)(E2402), canister (A7000), and wound care set (A6550). 
 
You asked the Plan to pre-approve the NPWT, canister, and wound care set. You say that the items are 
medically necessary. The Plan denied your request. The Plan says the member has been continuously using the 
negative pressure wound therapy pump for at least six (6) months for the same wound.  
The Plan must follow Medicare rules. Medicare rules say that negative pressure wound therapy pumps are not a 
covered benefit beyond four (4) months of continuous therapy for the same wound.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the NPWT, canister, and wound care set have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Negative pressure wound therapy electrical pump (NPWT)(E2402), canister 
(A7000), and wound care set (A6550).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hereditary cardiovascular screening panel testing provided on 
September 29, 2021. 
 You asked the Plan to pay for genetic testing. You say that you provided medically necessary testing in good 
faith. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because this 
testing is not covered for screening purposes. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, genetic testing, was performed for screening purposes. Medicare does not cover 
this test for screening purposes. Therefore, we decided that the Plan does not have to pay for hereditary 
cardiovascular screening panel testing provided on September 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient hospital services provided on November 3, 
2021. 
 
You asked the Plan to pay for the outpatient hospital services. You say that the services were medically 
necessary and should be paid as billed. The Plan denied your request. The Plan says this claim is not payable 
because condition code G0 was not used. 
 The Plan must follow Medicare rules. Medicare rules say that outpatient hospital claims are processed through 
the I/OCE which includes edits which affect payment in various ways. 
 
We looked at the file and Medicare rules. In this case, OCE edit 42 was invoked. This edit means that "multiple 
medical visits (based on units and/or lines) are present on the same day with the same revenue code, without 
condition code G0 to indicate that the visits were distinct and independent of each other". The claim was 
reviewed, and we find this is correct as both G0402 and G0463 were reported, and condition code G0 is not 
present. The disposition for this edit is to return the claim to provider, i.e., deny payment. This claim can be 
resubmitted with this edit corrected. Based on this information, we decided that Medicare rules for coverage of 
the outpatient hospital services have not been met. Therefore, we decided that the Plan does not have to pay for 
the outpatient hospital services provided on November 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed (E0265). 
 
You asked the Plan to pre-approve the total electric hospital bed. You say that the hospital bed is medically 
necessary. The Plan denied your request. The Plan says this type of hospital bed is non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed (E0265).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics (L3000). 
 
You asked the Plan to pre-approve foot orthotics (L3000). You say that you would like the Plan to reconsider 
their denial. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics (L3000).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve destruction by neurolytic agent, genicular nerve 
branches including imaging guidance, when performed (CPT code 64624). 
 
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your 
request. The Plan says this type of injection because it is not considered proven, and it 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 service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is limited published, large-scale, long-term peer-reviewed literature that shows this 
request to be an effective and/or safe treatment for the noted pathology. 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 destruction by neurolytic agent, genicular nerve branches including imaging 
guidance when performed (CPT 64624) 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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve destruction by neurolytic agent, genicular nerve branches including imaging guidance, 
when performed (CPT code 64624).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the vesiculectomy (55650) provided on October 6, 2021. 
 
You asked the Plan to pay for the vesiculectomy (55650). You say that the medical documentation attached 
supports CPT code 55650. The Plan denied your request. The Plan says procedure codes 55866 and 38571 
were approved and procedure code 55650 remains denied as the medical records do not support this 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 55650 is vesiculectomy, any approach. 
 
 
  We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the vesiculectomy (55650). Our reviewer says that the 
documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer found that 
the procedure is not described in the report to confirm this procedure has been performed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the vesiculectomy (55650) have not been met. Therefore, we decided that the 
Plan does not have to pay for the vesiculectomy (55650) provided on October 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says other 
causes of pain have not been ruled out. 
 
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 has chronic low back pain. On physical examination there was positive facet 
loading. There was no midline lumbar tenderness or paralumbar tenderness at L2. Magnetic Resonance 
Imaging (MRI) showed facet joint degeneration and small facet effusions at L5-S1 that were not significantly 
changed from two years prior. The facet joints at L1-L5 were normal per the radiologist. Although the imaging 
findings were consistent with facet joint abnormalities at L5-S1, the medial branch blocks were requested to be 
performed at L3-L5. In addition, the enrollee has a documented subacute compression fracture at L2. She has 
been non-complaint with wearing her back brace, which could be causing/contributing to her back pain. The 
review has determined that the records did not show that the coverage criteria have 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint injections.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the intracept procedure for the enrollee's back pain 
(CPT code 64628). 
 
You asked the Plan to pre-approve the service. You say that the technology improves the net health outcome of 
patients suffering from chronic low back pain. The Plan denied your request. The Plan says unproven and not 
medically necessary procedures are not covered by Medicare due to insufficient evidence of efficacy. 
 
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 service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the intracept procedure is experimental. More research is needed. 
 
 
 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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the intracept procedure for the enrollee's back pain (CPT code 64628).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve aquatic therapy services (97113 x6). 
 
You asked the Plan to pre-approve aquatic therapy services.  
The Plan denied your request. The Plan says you have had several sessions of aquatic therapy with no 
functional improvement. The Plan also says that you have not demonstrated that you cannot tolerate land-based 
therapy. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve aquatic therapy services. Our reviewer 
says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the 
enrollee's condition. Our physician reviewer found the additional requested therapy generally is not accepted as 
specific and effective therapy for your condition beyond what was approved by the health plan. The patient has 
had prior therapy and the documentation does not reveal that you require the unique skills of a professional 
therapist to safely and effectively provide treatment, that the services can be safely and effectively performed 
only by a therapist, or by or under the supervision of a therapist. Our reviewer found that you have been 
instructed in a home exercise program and should be able to participate in land-based therapy. The requested 
services are not part of a maintenance program, and the specialized skill, knowledge and judgment of a 
qualified therapist is not required to establish, design and/or deliver a program to maintain your current 
condition or to prevent or slow further deterioration. Our physician reviewer also found that there has been 
instruction in an independent home program. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of aquatic therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve aquatic therapy services (97113 x6).
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 IRF care is medically reasonable and necessary. The 
Plan denied your request. The Plan says rules for IRF care have not been met. 
 
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 that the patient has a past medical history of end stage renal disease on hemodialysis, 
congestive heart failure, atrial fibrillation, and obesity and is living at home with weakness and difficulty 
ambulating. Medical problems are stable. There are no complex nursing or rehabilitation needs. The patient 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. While the patient has a need for physical and/or occupational 
therapy, there is no documentation of a need for an intensive rehabilitation program. In conclusion, there is not 
a reasonable expectation that this patient 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.