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

 
We decided that the Plan has to pre-approve Azacitidine and cladribine 
 
You asked the Plan to pre-approve Azacitidine and cladribine. You say that the enrollee has already been 
started on the regimen of Azacitidine and cladribine. The Plan denied your request. The Plan says that the use 
of Azacitidine and cladribine for chronic myelomonocytic leukemia (CMML)/myelodysplastic syndromes 
(MDS) is not FDA-approved or listed in the Medicare approved sources. 
 
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 Azacitidine and cladribine. Our 
reviewer says that the criteria for coverage have been met. Our physician reviewer found the use of the 
requested drugs is supported by clinical research that appears in a Medicare-approved medical journal. An 
article on a retrospective study of cladribine and low-dose cytarabine-based regimens for the treatment of 
chronic myelomonocytic leukemia and secondary acute myeloid leukemia supports the use of the requested 
drugs. The use of these drugs is not listed as not indicated, not supported or not recommended in any of the 
compendia. The documentation supports that the requested drugs are safe and effective and otherwise 
reasonable and necessary 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 Azacitidine and cladribine have been met. Therefore, we decided that the Plan 
has to pre-approve Azacitidine and cladribine  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve revascularization services represented by codes 37224, 
37225, 37226, and 37228. 
 
You asked the Plan to pre-approve the revascularization services. You say that the records provided support the 
need for the services in dispute. The Plan denied your request. The Plan says the criteria for coverage 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 the revascularization services. Our 
reviewer says that the requested revascularization services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the enrollee was seen in January 2023, just weeks prior to 
her most recent evaluation. Her symptoms were thigh and leg cramping at night without cramping with 
ambulation. She has undergone invasive angiographic procedures almost every 3 months in 2022, including 
March 9, 2022, June 22, 2022, and October 19, 2022, all on the left leg and a right leg intervention on 
November 18, 2022. On October 19, 2022, it was demonstrated she did not have residual disease on the left. 
None of the findings would explain the enrollees thigh symptoms. The current noninvasive vascular study is not supported by a recent standard ankle-brachial index (ABI). For a procedure to be considered medically 
necessary, one of the criteria is that it be safe and effective. This would be the fourth invasive arterial procedure 
on the left leg in less than one year.  Therefore, these treatments have not demonstrated themselves to be 
effective.  Peripheral intervention in the absence of limb threat, particularly tibial interventions, can potentially 
do more harm than good. 
 
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 revascularization services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve revascularization services represented by codes 37224, 37225, 37226, and 
37228.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vectibix. 
 
You asked the Plan to pre-approve Vectibix. You say that , given the effectiveness of panitumumab in 
combination with nab-paclitaxel and carboplatin in patients with treatment-refractory renal medullary 
carcinoma (RMC), you strongly believe that it is necessary for the well-being of the enrollee. The Plan denied 
your request. The Plan says there is no documentation supporting the enrollee's tumor is epidermal growth 
factor receptor (EGFR) positive. The Plan says that the clinical value and effectiveness of Vectibix in the 
setting of metastatic renal medullary cancer have not been demonstrated in the peer-reviewed literature. The Plan says that the denial of Vectibix in combination with Abraxane and carboplatin was appropriate given the 
clinical scenario. 
 
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 Vectibix. Our reviewer says that 
Vectibix is not considered medically reasonable and necessary in this case. Our physician reviewer found the 
enrollee has metastatic medullary renal cancer. The requested use of Vectibix is not FDA-approved for the 
enrollee's diagnosis. The use of the requested drug in this setting is not supported by one of the major drug 
compendia or by clinical research that appears in a Medicare-approved medical journal. The documentation 
does not support that the requested drug is safe and effective and otherwise reasonable and necessary for this 
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 Vectibix have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Vectibix.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71045 provided on August 6, 2022. 
 
You asked the Plan to pay for procedure code 71045. You say that the medical records support the use of 
modifier XE with code 71045. The Plan denied your request. The Plan says the medical records do not support 
the use of modifier XE with code 71045. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. Medicare rules also say that the provider, 
supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to 
determine whether payment is due and the amount of payment. 
 
In this case, we have confirmed that code 71045 is a column II code to column I code 71046; however, 71045 
was 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 procedure code 71045. Our reviewer says that the medical 
records do not support the use of modifier XE with code 71045. Our reviewer found the medical record 
includes 2 chest x-rays performed at different times on same date of service. First single view chest x-ray for 
"PTX with tube to suction and was compared to a previous chest x-ray.  Second was a 2-view chest x-ray for 
"eval PTX after CT to water seal".  In this case, the medical record does not include sufficient documentation 
to support the need for 2 chest x-rays, and therefore modifier XE 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 71045 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 71045 provided on August 6, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the magnetic resonance elastography (MRE) provided on 
August 19, 2022. 
 
You asked the Plan to pay for the MRE as billed. You say that the claim has been billed with the appropriate 
diagnoses. The Plan denied your request. The Plan says the diagnosis code listed as primary is not an 
appropriate primary diagnosis code. 
 The Plan must follow Medicare rules. Medicare rules say that provider must comply with ICD-10-CM Coding 
guidelines. The guidelines indicate that certain conditions have both an underlying etiology and multiple body 
system manifestations due to the underlying etiology. For such conditions, the ICD-10-CM has a coding 
convention that requires the underlying condition be sequenced first, if applicable, followed by the 
manifestation. 
 
We looked at the file and Medicare rules. This claim was billed with primary diagnosis code K74.01. This code 
has a "code first" note indicating that the underlying condition should be sequenced first. As such, this is not an 
appropriate primary diagnosis code. Based on this information, we decided that Medicare rules for coverage of 
the MRE as billed have not been met. Therefore, we decided that the Plan does not have to pay for the 
magnetic resonance elastography (MRE) provided on August 19, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital services (procedure codes 99223, 99497) provided 
to the enrollee on March 9, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid or. The Plan denied your request. 
The Plan says the records do not support the services billed. 
 
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 the denied codes is: 
 
CPT 99223: 
 Initial hospital inpatient or observation care, per day, for the evaluation and management of a patient, which 
requires a medically appropriate history and/or examination and high level of medical decision making. When 
using total time on the date of the encounter for code selection, 75 minutes must be met or exceeded 
 
CPT 99497: 
 
Advance care planning including the explanation and discussion of advance directives such as standard forms 
(with completion of such forms, when performed), by the physician or other qualified health care professional; 
first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate 
 
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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the documentation does not meet 
the criteria for the level of service reported for CPT 99223. The medical decision making was of low 
complexity. Therefore, this is a more appropriate code to use for these services. In terms of CPT 99497, an 
appropriate modifier needs to be appended in this case. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for hospital services (procedure codes 99223, 99497) provided to the enrollee on March 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 96374 and 96375 provided on November 5, 
2021. 
 
You asked the Plan to pay for procedure codes 96374 and 96375. You say that the medical records support the 
use of modifier 59 with codes 96374 and 96375. The Plan denied your request. The Plan says the medical 
records do not support the use of modifier 59 with codes 96374 and 96375. 
 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 96374 and 96375 are column II codes to column I codes 78492, 
78434, and 93015; however, 96374 and 96375 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 procedure codes 96374 and 96375. Our reviewer says that 
the medical records do not support the use of modifier 59 with codes 96374 and 96375. Our reviewer found the 
documentation submitted was reviewed and procedure codes 96374 and 96375 do not meet criteria. The 
provider performed cardiac stress test; Myocardio imaging; and Mycardio blood flow imaging. Radiology 
report describes contrast given for the testing performed, which would not be reported separately from the 
radiological services performed. Therefore, modifier 59 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 codes 96374 and 96375 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 96374 and 96375 provided on November 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 continuous glucose monitor (CGM). 
 
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 criteria for coverage are not met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. There is no documentation supporting that you meet all of the criteria 
for coverage. The Plan requested records from your provider on two occasions and a response was not received. 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 Freestyle Libre 2 continuous 
glucose monitor (CGM).
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 are an excellent rehabilitation potential, highly 
motivated to regain your independence. The Plan denied your request. The Plan says you have not 
demonstrated the ability to perform intensive rehabilitation therapy 3 hours per day. 
 
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 there is not a reasonable expectation that the enrollee 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.
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 the enrollee is able to participate in therapy and 
needs IRF level of intensity to regain strength, mobility, and independence. The Plan denied your request. The 
Plan says based on Medicare guidelines and the information we have about the enrollee's condition, the IRF 
services requested do not meet the requirements. 
 
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 the enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. There is not a reasonable expectation that this enrollee will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF. Medically necessary care can 
be provided in a different level of care. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator (E0466). 
 
You asked the Plan to pre-approve a portable ventilator. You say that the enrollee has been hospitalized several 
times and is currently in the hospital requiring intubation, respiratory arrest for chronic hypercapnic and 
hypoxemic respiratory failure. The Plan denied your request. The Plan says the request for a home mechanical 
ventilator set in TTV-VAPS 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 portable ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found based on the medical records 
provided there is documentation of the diagnosis of chronic respiratory failure consequent to chronic 
obstructive pulmonary disease. Provided records document that the home ventilator is being requested for use 
in targeted tidal volume, volume assured pressure support (TTV-VAPS) mode with auto-titration (AE) which 
could be provided by a BiPAP device with average volume assured pressure support (AVAPS) and a back-up 
rate. As stated in the Local Coverage Determination (L33800): "Claims for ventilators used to provide CPAP 
or bi-level CPAP therapy for conditions described in this RAD policy will be denied as 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 a portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient injection(s), diagnostic or therapeutic agent, 
paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or 
CT), lumbar or sacral; single level (64493). 
 
You asked the Plan to pre-approve inpatient injections. You say that the injections are medically necessary. 
The Plan denied your request. The Plan says the request does not meet the Medicare or health plan coverage 
criteria. 
 
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 inpatient injections. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no medical justification for inpatient admission and or hospital facility 
lumbar facet joint injection. The procedure may be safely performed at an outpatient facility. An inpatient 
admission is not medically 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 inpatient injections have not been met. Therefore, we decided that the Plan does 
not have to pre-approve inpatient injection(s), diagnostic or therapeutic agent, paravertebral facet 
(zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or 
sacral; single level (64493).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation, intraoral x-ray, and endodontic 
therapy (D0140, D0220, D3330) provided on September 12, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says your $1,500 dental benefit maximum allowance 
for the requested item or service has 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 benefit for the requested item or service was exhausted on date of service September 13, 2022. 
Therefore, we decided that the Plan does not have to pay for a limited oral evaluation, intraoral x-ray, and 
endodontic therapy (D0140, D0220, D3330) provided on September 12, 2022.