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

 
We decided that the Plan does not have to pre-approve nuclear medicine study, single photon emission 
computed tomography (SPECT) imaging with concurrent computed tomography (CT) scan (78830). 
 
You asked the Plan to pre-approve SPECT imaging. You say that the enrollee is being evaluated for a 
transcatheter aortic valve replacement (TAVR) versus open heart surgery for severe aortic stenosis. You also 
say that cardiac amyloid needs to be ruled out. The Plan denied your request. The Plan says the requested 
service 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 SPECT imaging. Our reviewer says that 
the requested SPECT imaging is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the records do not show evidence of amyloid transthyretin (ATTR). The reviewer found there is no clinical evidence provided to support the performance of SPECT imaging in this enrollee according to 
current guidelines. Therefore, the reviewer found that the requested SPECT imaging is not medically 
reasonable and necessary in this enrollees 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 SPECT imaging have not been met. Therefore, we decided that the Plan does 
not have to pre-approve nuclear medicine study, single photon emission computed tomography (SPECT) 
imaging with concurrent computed tomography (CT) scan (78830).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroiliac (SI) joint radiofrequency ablation (RFA). 
 
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 enrollee has chronic right 
buttock and thigh pain due to sacroiliitis. He has been treated with medication including opiates, and bilateral 
SI joint injections. The requested SI joint RFA is considered experimental/investigational in nature and is not 
been proven effective. The services are therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve sacroiliac (SI) joint radiofrequency ablation (RFA).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure (64628). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this procedure is medically necessary. 
The Plan denied your request. The Plan says coverage criteria has 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 the Intracept procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this procedure is experimental for the enrollee's diagnosis. More research is needed to 
show safety and efficacy. 
 
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 an Intracept procedure (64628).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Dronabinol. 
 You asked the Plan to pre-approve Dronabinol. You say that the patient requires this drug as she has severe 
malnutrition as a result of nausea and lack of appetite. The Plan denied your request. The Plan says this drug is 
not covered under the patient's medical benefits because you indicated that this drug will not be administered 
within 2 hours of chemotherapy treatment and that the usage of the drug will extend beyond 48 hours from the 
chemotherapy administration. 
 
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 Dronabinol.  
 
Benefits for Dronabinol 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Feraheme.  
You asked the Plan to pre-approve Feraheme. The Plan denied your request. The Plan says the enrollee has not 
met the step therapy criteria. 
 
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 Feraheme. Our reviewer says that 
Feraheme is not medically reasonable and necessary in this case. Our physician reviewer found that there is no 
indication that the enrollee has tried and failed the required drug(s). Based on the medical records provided and 
the Medicare-approved major drug compendia there is no indication that the Plan's required drug(s) would 
likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Feraheme have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Feraheme.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI). 
 
You asked the Plan to pre-approve SSBCI benefits. You say that you feel you meet criteria for benefits. The 
Plan denied your request. The Plan says it does not appear that you meet criteria for SSBCI benefits. Medical 
records were not provided to review whether criteria for benefits are met. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
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 SSBCI benefits have been met. The 
record shows that the Plan made multiple attempts to obtain this information, but it was not received. Without 
medical records we are unable to determine if you meet the criteria for coverage. Therefore, we decided that the 
Plan does not have to pre-approve special supplemental benefits for the chronically ill (SSBCI).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ramp. 
 
You asked the Plan to pre-approve a ramp. You say that the item is medically necessary. The Plan denied your 
request. The Plan says this is a convenience item and not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a ramp.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF services to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve IRF services. You say that the member has been rejected by providers in the 
area stating skilled nursing is needed. The Plan denied your request. The Plan says the requested service is 
available with an in-network provider 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
IRF services to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Imfinzi and Tremelimumab-actl. 
 
You asked the Plan to pre-approve Imfinzi and Tremelimumab-actl. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the requested drugs are not medically necessary. 
 
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 Imfinzi and Tremelimumab-actl. Our 
reviewer says that the documentation does not support that the requested drug is medically reasonable or 
necessary. Our physician reviewer found the enrollee has a diagnosis of liver cancer.  
 The record indicates that the requested regimen is being used as second line therapy and that the enrollee has 
progressed while receiving PDL-1 receptor directed therapy. The Food and Drug Administration has not stated 
that the requested drug is indicated for the enrollee's condition. The Medicare approved cancer drug compendia 
do not contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. 
Therefore, the enrollee does not meet criteria for the requested drugs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Imfinzi and Tremelimumab-actl have not been met. Therefore, we decided that 
the Plan does not have to pre-approve Imfinzi and Tremelimumab-actl.
Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pay for 35372 and 37226. We decided that the Plan does not have to pay for 
35351 and 37799.  
 
You asked the Plan to pay for surgical services (procedure codes 35351, 35372, 37226, 37799) rendered on 
November 16, 2022.. You say that this should be paid for. The Plan says that the records do not support the 
services billed. 
 
We decided that the Plan has to pay for 35372 and 37226.  
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
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 for CPT 35372 and CPT 37226. Our reviewer says that 
while it appears that an extensive exposure and endarterectomy was performed at the groin, one cannot bill 
separately for each vessel treated via the same arteriotomy.  Since there is satisfactory documentation that the 
deep femoral artery was one of the vessels exposed and treated/patched the code for deep femoral 
endarterectomy (CPT 35372) can be used. Additionally, there is satisfactory documentation that a superficial 
femoral artery (SFA) sent was placed. Therefore, CPT 37226 is supposed. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
35372 and 37226.  
 
We also decided that the Plan does not have to pay for 35351 and 37799. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
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 for CPT 35351 and 37799. Our reviewer says that CPT 
353551 cannot also be billed with CPT 35372. With respect to CPT 37799, another more applicable code may 
be available. An alternate code must be used for the iliac angioplasty portion of the 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 35351 and 37799 have not been met. Therefore, we decided that the Plan does 
not have to pay for 35351 and 37799. 
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says the request is not 
supported by the records. 
 
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 pre-approve SNF services. Our physician reviewer 
found that the enrollee received oral medications and had stable vital signs. There are no identifiable skilled 
nursing services. Regarding rehabilitation services, the enrollee was at a supervision to moderate assist level 
with functional mobility. There are identifiable skilled therapy service needs. However, the enrollee does not 
require skilled nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or 
intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 75726 and 75774 billed for date of service 
August 23, 2022. 
 You asked the Plan to pay for procedure codes 75726 and 75774. The Plan denied your request. The Plan says 
payment for codes 75726 and 75774 is bundled into payment for code 37244. 
 
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 codes 
75726 and 75774 are column II codes to column I code 37244. 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 codes 75726 and 75774 billed for 
date of service August 23, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex interspinous stabilization device. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says there 
are not enough studies to show it is 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 requested services. Our physician 
reviewer found that The Vertiflex device is experimental. More research is needed to show its safety and 
efficacy. Therefore, the request is not considered 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Vertiflex interspinous stabilization device.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ZIP spinal device. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee has failed conservative 
treatment. The Plan denied your request. The Plan says the service is considered experimental and 
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 the requested services. Our physician 
reviewer found that the requested ZIP interspinous fusion system is considered experimental. More research is 
needed to show its safety and efficacy. Therefore, the request is 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a ZIP spinal device.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided on October 20, 2022. 
 
You asked the Plan to pay for imaging services provided. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed codes. 
 
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 codes 95910-26 and 95886-26 (x2) is nerve conduction 
studies; 7-8 studies, and needle electromyography, each extremity, with related paraspinal areas, when 
performed, done with nerve conduction, amplitude and latency/velocity study; complete, five or more muscles 
studied, innervated by three or more nerves or four or more spinal levels.  
 
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 imaging services provided. Our reviewer says that documentation does not support the billed codes. Our reviewer found code 95910 was reported for pedicle 
screw stimulation. This does not meet the criteria to report 7-8 nerve conduction studies. There is a more 
specific code for this procedure. In addition, code 95886 is an add on code and cannot be billed with an invalid 
primary procedure code. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of imaging services provided have not been met. Therefore, we decided that the 
Plan does not have to pay for imaging services provided on October 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on August 7, 2022, billed with 
codes 0031U, 0032U, 0033U, 81230, 81231, 81232, 81238, 81291, 81306, 81335, 81355, 81406, 81407 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 panel testing should be billed 
using one CPT code on the claim. 
 
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 
August 7, 2022, billed with codes 0031U, 0032U, 0033U, 81230, 81231, 81232, 81238, 81291, 81306, 81335, 
81355, 81406, 81407 and 81479.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a raised toilet seat. 
 
You asked the Plan to pre-approve a raised toilet seat. You say that it is hard to utilize the restroom. You also 
say that you have tried using a regular seat and were not able to get up. The Plan denied your request. The Plan 
says the requested item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that raised toilet seats are not covered 
because they are not primarily medical in nature.  
 
While a raised toilet seat may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a raised toilet seat.