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

 
We decided that the Plan does not have to pre-approve the Allograft patch (29999). 
 
You asked the Plan to pre-approve the Allograft patch. You say that please reconsider CPT code 29999 for 
possible patch with rotator cuff repair surgery. The Plan denied your request. The Plan says this service is 
considered experimental and investigational. There is insufficient evidence of its efficacy. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Allograft patch have not been met. Therefore, we decided that the Plan does not have to pre-
approve the Allograft patch (29999).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital services provided to the enrollee from November 30, 
2021, to December 29, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that the routine items and services should not have been reported separately. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The plan has not specified in the case file which services have been denied with 
denial code G. Our coding reviewer found that after a careful review of the charges found on page 2-31 of the 
600-page additional information document, it is undetermined which items were denied with denial code 
G. Itemized bill includes total charges in the amount of $220,713. 66. In this case, the denied charges cannot be 
verified. Therefore, we decided that the Plan has to pay for inpatient hospital services provided to the enrollee 
from November 30, 2021, to December 29, 2021.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for magnetic resonance imaging (MRI) of the spine provided to 
the enrollee on October 21, 2021. 
 
You asked the Plan to pay for the MRI. You say that the services were medically necessary. The Plan denied 
your request. The Plan says the records submitted do not support the procedure code. 
 
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 72148 is "Magnetic resonance (eg, proton) imaging, 
spinal canal and contents, lumbar; without contrast material." 
 
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 MRI. Our reviewer says that the services at issue in this 
case were not supported by the medical records. Our reviewer found that the medical record includes a 
radiological report which describes thoracic vertebral bodies MRI. CPT 72148 represents MRI spinal canal and 
contents, lumbar. There is a more appropriate code that should be reported for service provided. Therefore, 
CPT 72148 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 the MRI have not been met. Therefore, we decided that the Plan does not have 
to pay for magnetic resonance imaging (MRI) of the spine provided to the enrollee on October 21, 2021.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 31237 provided to the enrollee on January 21, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that 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 
code 31237 is "Nasal/sinus endoscopy with biopsy/polypectomy/debridement." 
 
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 supported by the medical records. Our reviewer found that in this case, the procedure report 
describes an endoscopy was performed, then debridement. Therefore this procedure is verified, in the medical 
record for date of service January 21, 2022.  
 
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 been met. Therefore, we decided that the Plan has to pay for 
procedure code 31237 provided to the enrollee on January 21, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Pembrolizumab (J9271). 
 
You asked the Plan to pre-approve the drug. You say that the enrollee has stage four cancer that is progressing, 
and the physician wants to give the enrollee Keytruda, Carboplatin, and Alimta because it is the best option for 
them. The Plan denied your request. The Plan says Pembrolizumab does not meet the Medicare or health plan 
coverage criteria. 
 
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 the drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found that the requested use of 
Pembrolizumab is not Food and Drug Administration (FDA) approved for progression of disease on prior 
PDL1 inhibitor therapy. 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 the drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Pembrolizumab (J9271).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for hearing aid services provided on May 2, 2022. 
 
You asked the Plan to reimburse you for the hearing aid services. You say that the hearing services were 
medically necessary. The Plan denied your request. The Plan says there was no evidence that seeing a provider 
within the Plan's hearing provider network would be detrimental to your health or that it is medically necessary 
for you to see a provider outside of the Plan's hearing provider network. In addition, the bill submitted is not a 
valid proof of payment because the receipt did not show what was purchased (type of hearing aid, model, etc.) 
or service rendered at time of service. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case.  
 
We looked at the file and the Plan's rules. The file shows that the hearing services were not provided by the 
Plans hearing provider. Based on this information, we decided that the Plan's rules for coverage of the hearing 
aid services have not been met. Therefore, we decided that the Plan does not have to reimburse you for hearing 
aid services provided on May 2, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve left heart catheterization services. 
 
You asked the Plan to pre-approve left heart catheterization services. You say that the records provided support 
the need for the requested services. The Plan denied your request. The Plan says left heart catheterization is not 
recommended unless there is evidence of at least mild ischemia on imaging or significant obstructive coronary 
artery disease on coronary computed tomography angiography (CCTA.) 
 
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 left heart catheterization services. Our 
reviewer says that left heart catheterization services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the patient has been evaluated with a radionuclide stress test which was 
negative for ischemia, and an echocardiogram showing preserved left ventricular function. Documentation does 
not support the rationale for this invasive imaging study. Guidelines do not support a need for cardiac 
catheterization in this setting. As a result, at this time cardiac catheterization would not be considered 
medically appropriate and necessary in this patients 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 left heart catheterization services have not been met. Therefore, we decided that 
the Plan does not have to pre-approve left heart catheterization services.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for an emergency room (ER) visit and a 
drainage procedure provided from July 16, 2022, to August 11, 2022. 
 
You asked the Plan to waive the copayments for the ER visit and drainage procedure. You say that you 
developed an infection resulting in the ER visit and drainage, and you should not be responsible for those 
charges. 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 a $90 
copayment for emergency care and a $285 copayment for outpatient hospital facility visits.  
 
 
  You have been asked to pay a $90 copayment for the ER visit. This item/service falls within the emergency 
care benefit category. You have also been asked to pay a $285 copayment for the drainage procedure. This 
item/service falls within the outpatient hospital facility visits 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 copayments for an emergency room (ER) visit and a drainage procedure provided from July 16, 
2022, to August 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for domiciliary, rest home, or custodial care visits provided from 
August 5, 2022 to September 16, 2022, by an out-of-network provider. 
 
You asked the Plan to pay for the domiciliary, rest home, or custodial care visits. The Plan denied your request. 
The Plan says the service was rendered by an out-of-network supplier, which required authorization and there 
is not one on file. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for domiciliary, rest home, or custodial care visits provided from 
August 5, 2022 to September 16, 2022, by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve spinal fusion surgery. 
 
You asked the Plan to pre-approve spinal fusion surgery. You say that the records provided support the need 
for the surgery in dispute. You say that holding off on this surgery could put the enrollee's future at risk with 
regaining strength and mobility. The Plan denied your request. The Plan says the requested surgery is not for 
instability in the spine or because of a failed previous surgery. The Plan says that the requested surgery 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 spinal fusion surgery. Our reviewer 
says that spinal fusion surgery is not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no documented spinal instability, fracture, or lesion. There is no severe deformity. 
Multilevel spinal fusion surgery 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 spinal fusion surgery have not been met. Therefore, we decided that the Plan 
does not have to pre-approve spinal fusion surgery.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ingrezza. 
 
You asked the Plan to pre-approve Ingrezza. You say that the requested drug is medically necessary. The Plan 
denied your request. The Plan says the requested medication does not fall under Part B coverage. The Plan says 
that they do not administer pharmacy benefits for the enrollee. 
 
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 Ingrezza.  
 
Benefits for Ingrezza 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMs Heart Failure (HF) system. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the CardioMEMs device was approved 
by the Food and Drug Administration (FDA) in 2014. Nonetheless, there remains a dearth of randomized, 
blinded clinical studies examining long-term clinical outcomes establishing the value of CardioMEMS in 
patient management. As a result, at this time the CardioMEMS system would not be considered medically 
appropriate and necessary in the enrollee's clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a CardioMEMs Heart Failure (HF) system.  National Coverage Determination (NCD) 310.1 referenced by the Plan is not binding for the services at issue 
and was not used in the MAXIMUS determination.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee from September 21, 2021, to September 30, 2021. 
 
You asked the Plan to pay for the services. You say that you submitted supporting documentation for 
reconsideration of this adjustment. The Plan denied your request. The Plan says the provider has reported 
skilled services with the incorrect PDPM Health Insurance Prospective Payment System (HIPPS) score. 
 
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 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 supported by the medical records. Our reviewer found that the enrollee is noted to have 
previously had a stroke. There is no evidence that the enrollee had acutely suffered a stroke or that her prior 
stroke had a direct relationship to her current SNF care. The enrollee had a feeding tube, but the tube appears to 
have been related to her liver disease and poor PO intake, not an inability to eat (i.e., dysphagia) caused by her 
prior stroke. 
 
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 skilled nursing facility (SNF) services provided to the enrollee from September 21, 2021, to 
September 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the PureWick Urine Collection System (K1006). 
 
You asked the Plan to pre-approve incontinence supplies. You say that you received a denial letter advising 
that the requested system would not be covered The Plan denied your request. The Plan says Medicare does not 
cover the PureWick external female urinary incontinence system. Medicare does not consider the device as 
meeting the definition of DME. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve the PureWick Urine Collection 
System (K1006).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for retinopathy treatment provided on January 4, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the retinopathy treatment. You say that the services were medically necessary. 
The Plan denied your request. The Plan says unauthorized, out-of-network care is not covered. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider at issue in this case is not a network provider with the Plan. 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 pay for the retinopathy treatment. Our reviewer says that the records do not indicate that 
the care provided was medically necessary. Our physician reviewer found there was no documentation of acute 
vision loss, severe eye pain, or uncontrolled intraocular pressure. It would have been medically reasonable to 
delay the services until the enrollee returned to their service area. 
 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 retinopathy treatment have not been met.  
 
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 pay for the retinopathy treatment. Therefore, we decided that the 
Plan does not have to pay for retinopathy treatment provided on January 4, 2022, by an out-of-network (OON) 
provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Special Supplemental Benefits for the Chronically 
Ill (SSBCI) benefits. 
 
You asked the Plan to pre-approve the SSBCI benefits. You say that you are appealing the denial. The Plan 
denied your request. The Plan says there is no documentation that the enrollee meets criteria. 
 
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 the SSBCI benefits have been met. 
medical records. Therefore, we decided that the Plan does not have to pre-approve the Special Supplemental 
Benefits for the Chronically Ill (SSBCI) benefits.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex Superion Interspinous device (22869). 
 
You asked the Plan to pre-approve the Vertiflex device. You say that you feel the enrollee is an excellent 
candidate for this minimally invasive procedure and should have access based on medically necessity ans 
strong level 1 clinical evidence supporting the efficacy and safety of this procedure. The Plan denied your 
request. The Plan says this is considered experimental and investigational. Medical studies have not proven this 
service is helpful for the treatment of the enrollee's health problem. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Vertiflex device have not been met. Therefore, we decided that the Plan does not have to pre-
approve the Vertiflex Superion Interspinous device (22869).