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

 
We decided that the Plan does not have to pre-approve continued treatment with Yutiq (J7314). 
 
You asked the Plan to pre-approve Yutiq. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says rules for coverage have not been met because the 
prescribed use of the requested drug is off-label and not medically accepted. 
 
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 Yutiq. Our reviewer says that the 
requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the 
requested use of Yutiq is not FDA-approved for the enrollee's diagnosis. Re-implantation prior to 36 months is 
not supported by the Medicare-approved major drug compendia. 
 
 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Yutiq have not been met. Therefore, we decided that the Plan does not have to 
pre-approve continued treatment with Yutiq (J7314).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure (64629). 
 
You asked the Plan to pre-approve an Intracept procedure. You say that the requested services are a medical 
necessity for you. The Plan denied your request. The Plan says rules for coverage have not been met because 
the requested services are experimental/investigational. 
 
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 an Intracept procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the Intracept procedure is experimentaL. More research is needed to demonstrate 
the safety and effectiveness of the requested procedure. 
 
 
  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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure (64629).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton bean radiation therapy (PBRT). 
 
You asked the Plan to pre-approve PBRT. You say that the services are necessary. The Plan denied your 
request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been 
met. 
 
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 PBRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found to date, there are no compelling data to suggest that proton therapy is superior to or more 
beneficial than Intensity-modulated radiation therapy/Image-guided radiation therapy (IMRT/IGRT). The 
generally accepted standard of care for prostate cancer is to only offer proton beam therapy on clinical trials, 
and to not routinely offer it to patients. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PBRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve proton bean radiation therapy (PBRT).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and a complete 
mandibular denture (D5120). 
 
You asked the Plan to pre-approve the complete dentures. You say that you need new dentures because the 
other ones did not fit you. The Plan denied your request. The Plan says your benefits for the requested dentures 
have already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefits for the requested dentures were exhausted on date of service September 9, 2021. 
Therefore, we decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and a 
complete mandibular denture (D5120).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the ventilator is to be used for the treatment 
of COPD. The Plan denied your request. The Plan says the request for a home mechanical ventilator set in 
AVAPS mode with Auto-EPAP (AE) that could be delivered by BiPAP is not covered. 
 
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 service is not medically necessary. Our physician reviewer found the record indicates that you were 
admitted with a urinary tract infection in the setting of hypercarbic chronic respiratory failure from chronic 
obstructive pulmonary disease. The provided primary source documentation does not contain sufficient detailed 
information in the medical record to justify the treatment selected. You could be treated with a BiPAP machine 
with AVAPS capability. The plan has indicated coverage for such a device is available upon request. The 
elements of the coverage criteria are not satisfied. The requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unlisted computed tomography procedure coded 76497 
provided on January 26, 2022. 
 
You asked the Plan to pay for the unlisted computed tomography procedure. You say that you would like this 
claim reprocessed and approved for payment. The Plan denied your request. The Plan says no separate payment 
can be made for code 76497. 
 
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 76497 is unlisted computed tomography procedure (eg, 
diagnostic, interventional). 
 
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 unlisted computed tomography procedure. Our reviewer 
says that the documentation does not support payment for the services billed. Our reviewer found that there is 
no support in the documentation provided for payment for an unlisted computed tomography procedure. This 
payment s appropriately included in the payment for CPT 71275. 
 
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 unlisted computed tomography procedure have not been met. Therefore, we 
decided that the Plan does not have to pay for the unlisted computed tomography procedure coded 76497 
provided on January 26, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on April 6, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that this laboratory does not have 
a contract with the dialysis facility for payment. The Plan denied your request. The Plan says Medicare does 
not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on April 6, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the device is medically necessary. The Plan 
denied your request. The Plan says the request for a home ventilator does not meet the requirement for 
approval. 
 
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 service is not medically necessary. Our physician reviewer found the enrollee has COPD, but 
pulmonary function testing results are not provided.  There is no documentation of chronic CO2 retention on an 
ABG done while stable.  Even if the enrollee did have chronic CO2 retention, BiPAP with AVAPS would 
likely meet the enrollee's needs. Medicare does not cover a home ventilator when used as 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 (E0466).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) care provided 
on January 1, 2022, to January 13, 2022. 
 
You asked the Plan to waive the copayment for SNF. You say that they did not authorize additional days and 
only wanted to stay for the days the insurance would cover. The Plan denied your request. The Plan says this 
cost sharing was charged correctly. 
 
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 $188 
copayment each day for Medicare-covered days 21 to 57 for SNF care. You previously received 14 days of 
SNF care in December 2021. This SNF care lasted 12 days, which days 15 to 26 of the SNF benefit period, 
resulting in copayment amount of $1,128 ($188 per day for 6 days = $1,128). 
 
You have been asked to pay $188 copayment each day for Medicare-covered days 21 to 57 for SNF. This 
item/service falls within the SNF care 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 waive the copayment for 
skilled nursing facility (SNF) care provided on January 1, 2022, to January 13, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient hospital admission from September 30, 2022, 
through October 13, 2022. 
 
You asked the Plan to pre-approve the inpatient hospital admission. You say that the services were medically 
necessary. The Plan denied your request. The Plan says the services were 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 inpatient hospital admission. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found during this time period the enrollee did not require or receive any inpatient 
diagnostic studies or therapeutic interventions. 
 
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 inpatient hospital admission have not been met. Therefore, we decided that 
the Plan does not have to pre-approve inpatient hospital admission from September 30, 2022, through October 
13, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate (20939). 
 
You asked the Plan to pre-approve bone marrow aspirate. You say that the requested bone marrow aspirate 
(20939) is medically necessary. The Plan denied your request. The Plan says the requested bone marrow 
aspirate (20939) 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 bone marrow aspirate. Our reviewer 
says that the requested bone marrow aspirate (20939) is not medically necessary. Our physician reviewer found 
the enrollee was being treated for radiculopathy of the lumbar spine; spondylolisthesis of the lumbar region; 
scoliosis of the lumbar spine; and spondylolisthesis, site unspecified. He presented with pain in his low back 
and legs. He does have some mild balance problems that he feels are related to his lower back. The plan approved the L1-L5 lateral fusion with an inpatient stay. However, there is no specific indication provided to 
support the request for bone marrow aspirate for the approved surgery. There is a lack of large-volume, long-
term peer-reviewed outcome studies to support the use of bone marrow aspirate for this enrollees medical 
condition as discussed above. There is no compelling rationale presented or extenuating circumstances noted to 
support the medical necessity of this request as an exception. Therefore, the requested bone marrow aspirate 
(CPT 20939) for L1-L5 lateral fusion with an inpatient stay, 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 bone marrow aspirate have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bone marrow aspirate (20939).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a determination of a refractive state (92015) provided on 
May 26, 2022. 
 
You asked the Plan to pay for a determination of a refractive state (92015). You say that you paid and want to 
be reimbursed. The Plan denied your request. The Plan says they no longer cover refractions only.  
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when billed as part of the routine eye exam. 
 
We looked at the file and the Plan's rules. The Plan rules say that refractions are only covered when billed as 
part of the routine eye exam. Based on this information, we decided that the Plan's rules for coverage of a 
determination of a refractive state (92015) have not been met. Therefore, we decided that the Plan does not 
have to pay for a determination of a refractive state (92015) provided on May 26, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on October 5, 2021, billed with 
codes 81295, 81298, 81432 and 81479. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was necessary and is 
supported in the medical record. The Plan denied your request. The Plan says this claim was not billed in 
accordance with Medicare rules. 
 The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
October 5, 2021, billed with codes 81295, 81298, 81432 and 81479.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71275 billed for date of service September 
12, 2021. 
 
You asked the Plan to pay for procedure code 71275. You say that this service is supported in the medical 
record The Plan denied your request. The Plan says the records provided do not support the reporting of code 
71275. 
 
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 71275 is computed tomographic angiography (CTA), 
chest (noncoronary), with contrast material(s), including non-contrast images, if performed, and image 
postprocessing. 
 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 71275. Our reviewer says that this service is 
not supported by the records provided. Our reviewer found the medical record does not include documentation 
of a CTA of the chest. The medical record includes only documentation of a chest x-ray and abdominal/pelvis 
computed tomography (CT). Therefore, this procedure cannot be verified. 
 
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 71275 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 71275 billed for date of service September 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heavy-duty wheelchair (K0006). 
 
You asked the Plan to pre-approve a heavy-duty wheelchair. You say that the enrollee is a below the knee 
amputee. He is unable to ambulate with a walker or cane. The enrollee can self-propel in the wheelchair. The 
Plan denied your request. The Plan says the enrollee does not meet criteria for approval of the wheelchair. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
 
 
 
 
 
 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 heavy-duty wheelchair. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found although vendor-prepared notes 
and the wheelchair order form report necessity of the requested heavy-duty manual wheelchair, the provided 
medical records from his treating practitioner do not fully corroborate this. As stated in the Local Coverage 
Article, supplier-produced records, even if signed by the treating practitioner, and attestation letters (e.g., letters 
of medical necessity) are deemed not to be part of a medical record for Medicare payment purposes. Templates 
and forms, including CMS CMNs, are subject to corroboration with information in the medical record. A 
prescription is not considered to be part of the medical record. Medical information intended to demonstrate 
compliance with coverage criteria may be included on the prescription but must be corroborated by information 
contained in the medical record. The enrollee's medical record must contain sufficient documentation of his 
medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency 
of use or replacement (if applicable). The information should include the enrollee's diagnosis and other 
pertinent information including, but not limited to, duration of the enrollee's condition, clinical course 
(worsening or improvement), prognosis, nature and extent of functional limitations, other therapeutic 
interventions and results, past experience with related items, etc. 
 
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 heavy-duty wheelchair have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a heavy-duty wheelchair (K0006).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service February 17, 
2022. 
 You asked the Plan to pay for procedure code 70450. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says payment for code 70450 is bundled into 
payment for code 70496. 
 
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 procedure code 70450 billed for date of service February 17, 
2022.