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

 
We decided that the Plan does not have to pre-approve treatment with Ipilimumab (J9228) and Nivolumab 
(J9299). 
 
You asked the Plan to pre-approve Ipilimumab and Nivolumab. You say that the requested drug regimen is a 
medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not 
been met because the requested drug regimen has been prescribed for an off-label and medically unsupported 
use. 
 
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 Ipilimumab and Nivolumab. Our 
reviewer says that the requested drug regimen is not medically reasonable and necessary in this case. Our 
physician reviewer found that the requested use of Ipilimumab and Nivolumab is not FDA-approved for the 
enrollees diagnosis. The use 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 Ipilimumab and Nivolumab have not been met. Therefore, we decided that the 
Plan does not have to pre-approve treatment with Ipilimumab (J9228) and Nivolumab (J9299).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to adjust the cost share for the office visit (99203) provided on 
December 22, 2021. 
 
You asked the Plan to adjust the cost share. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the cost share has been applied correctly to the 
service provided. 
 
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 20% of the total cost for each Medicare covered 
specialist visit (including surgery second opinion, telehealth services, and urgently needed services). 
Additionally, you must pay a $300 annual deductible. This is the amount you have to pay out-of-pocket before 
the Plan will pay its share for your covered Medicare Part A and B services.  
 
You have been asked to pay $116.54 for the specialist office visit provided as you had not previously met the 
annual deductible. This is the Plans allowed amount for this service. 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 adjust the 
cost share for the office visit (99203) provided on December 22, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Watchman implant procedure (33340, 33999) to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a Watchman implant. You say that the requested procedure is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for out-of-network 
care have not been met. 
 
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 
a Watchman implant procedure (33340, 33999) to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractor services provided on November 11, 2021 to 
December 1, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the chiropractic service. You say that manipulation of the spine to correct 
subluxation is a covered service so this should be covered and so should the initial exam. The Plan denied your 
request. The Plan says enrollees must receive their medical services from an in-network provider with the 
exception being urgent or emergent services. Non-emergent services with non-contracted providers require 
prior authorization before services being rendered. 
 
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 had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the chiropractor services provided on November 
11, 2021 to December 1, 2021 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the right shoulder 
for the enrollee. 
 
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your 
request. The Plan says there has been no trial of physical therapy, occupational therapy, or home exercise for at 
least six weeks. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
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 MRI. Our reviewer says that the 
requested MRI is not medically reasonable or necessary. Our physician reviewer found no red flag is presented 
to mandate immediate MRI without a six week trial of physical therapy. 
 
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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve magnetic resonance imaging (MRI) of the right shoulder for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve positron emission tomography/computed tomography 
(PET/CT) scan from skull to mid-thigh for the enrollee. 
 
You asked the Plan to pre-approve the. You say that this is medically necessary. The Plan denied your request. 
The Plan says this is not supported for first staging of prostate cancer. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
medically necessary.  
 
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. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found the bone scan is a 
comforting test showing no evidence of boney mets. Medicare guidelines indicate that PET/CT is not allowed 
for initial staging and is indicated after treatment failure. So, computed tomography (CT) or MRI is the 
procedure that Medicare accepts for staging without prior treatment. 
 
 
 
 
 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 have not been met. Therefore, we decided that the Plan does not have to pre-
approve positron emission tomography/computed tomography (PET/CT) scan from skull to mid-thigh for the 
enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xolair. 
 
You asked the Plan to pre-approve Xolair. You say that the requested drug is medically necessary. The Plan 
denied your request. The Plan says the requested drug is not approved by the FDA for the enrollee's condition. 
 
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 Xolair. Our reviewer says that the 
requested drug, Xolair, is not medically necessary. Our physician reviewer found the provided documentation 
does not indicate that the enrollee is refractory to antihistamines and does not document an adequate 
antihistamine trial. The Food and Drug Administration has not stated that the requested drug is indicated for the 
enrollee's condition. The Medicare approved drug compendia do not contain a supportive citation for the use of 
the requested drug in the enrollee's clinical situation. Therefore, the reviewer found that the requested drug, 
Xolair, 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 Xolair have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Xolair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the vacuum device rendered on September 21, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that vacuum erection devices (L7900) and related 
accessories (L7902) are statutorily non-covered. 
 
We looked at the file and Medicare rules. The item at issue is a vacuum erection device. This item is not 
covered by Medicare. Therefore, we decided that the Plan does not have to pay for the vacuum device rendered 
on September 21, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services related to medical practitioner certification of a 
home health plan of care provided on October 22, 2021, billed with code G0180. 
 You asked the Plan to pay for the billed home health certification services. You say that this was medically 
necessary care that should be reimbursed as billed. The Plan denied your request. The Plan says G0180 was not 
reported with a required modifier to allow for separate payment when billed with 99337. 
 
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 G0180 
is a column II code to column I code 99337. 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 the services related to medical practitioner certification of a 
home health plan of care provided on October 22, 2021, billed with code G0180.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing provided on July 27, 2021. 
 
You asked the Plan to pay for drug testing. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the denial of payment for this service is correct, because the documentation 
submitted does not support the Place of Service (POS) code billed on this claim. 
 The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of drug testing have not been met. Specifically, this claim was billed with the laboratory POS code. 
The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that the 
Plan does not have to pay for drug testing provided on July 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit with an OON provider. 
 
You asked the Plan to pre-approve the office visit. You say that you saw this doctor in 2016 and would like to 
go back to him. The Plan denied your request. The Plan says being seen by an out-of-network provider is not 
medically necessary since they have a contracted provider that can provide the service requested. 
 
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 
an office visit with an OON provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex Superion Interspinous device for the 
enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that these services are not indicated. 
 
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 requested services are not considered medically reasonable and necessary in this case. The vertilflex device 
is experimental. More research is needed. Our physician reviewer found that the enrollee's condition does not 
meet criteria for coverage of these services. 
 
 
 
 
 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 the Vertiflex Superion Interspinous device for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a left reverse total shoulder replacement (CPT code 
23472) with inpatient stay. 
 
You asked the Plan to pre-approve the services. You say that you need your left shoulder replaced as soon as 
possible to increase functionality, decrease constant pain, and restore a better quality of life. The Plan denied 
your request. The Plan says the records sent in by your doctor show you have pain in your left shoulder with 
some age-related changes of the left shoulder. The Plan states imaging studies do not show there is/are a tear(s) 
in or significant shrinkage of the rotator cuff; therefore, they will not approve this procedure. 
 
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 services. Our reviewer says that 
detailed documentation is not evident regarding trial and failure of recent, reasonable, and comprehensive less 
invasive conservative care measures. Additionally, the computed tomography (CT) scan of the left upper 
extremity did not reveal rotator cuff pathology.  There are limited large-scale, long-term references showing the safety and efficacy of the requested procedure 
in this clinical setting. There is no compelling rationale presented or extenuating circumstances noted to 
support the medical necessity of this request as an exception to guidelines. Therefore, the requested left reverse 
total shoulder replacement (CPT 23472) with 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a left reverse total shoulder replacement (CPT code 23472) with inpatient stay.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says rules for coverage for drugs or biologicals have not been 
met. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be sent 
to the office for administration. Since the medication does not represent an expense to the physician and will 
not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that the Plan 
does not have to pre-approve treatment with Prolia.  
 
Benefits for Prolia 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for destruction by neurolytic agent procedures on the somatic 
nerves (CPT 64633, 64634) provided on January 21, 2022. 
 
You asked the Plan to pay for destruction by neurolytic agent procedures on the somatic nerves. The Plan 
denied your request. The Plan says destruction by neurolytic agent procedures on the somatic nerves does not 
meet the Medicare LCD coverage criteria. 
 
The Plan follows Medicare rules. Medicare rules say that for each covered spinal region no more than two (2) 
radiofrequency sessions will be reimbursed per rolling 12 months. 
 
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 destruction by neurolytic agent procedures 
on the somatic nerves. Our reviewer says that destruction by neurolytic agent procedures on the somatic nerves 
is not medically necessary. Our physician reviewer found that for each covered spinal region no more than two 
radiofrequency sessions will be reimbursed per rolling 12 months. Therefore, based on the Medicare 
guidelines, the requested repeat bilateral Facet Joint RFA at C3, C4, and C5 is considered 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 destruction by neurolytic agent procedures on the somatic nerves have not been 
met. Therefore, we decided that the Plan does not have to pay for destruction by neurolytic agent procedures on 
the somatic nerves (CPT 64633, 64634) provided on January 21, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested SNF care is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says medical necessity rules for SNF care have not been 
met. 
 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 care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found that there is no documentation that the 
enrollee requires skilled nursing services. The enrollee does require skilled therapy services; however, there is 
no documentation that daily skilled services are required. The available records do not document a significant 
decline in the enrollee's functional status to necessitate daily inpatient skilled therapy services. 
 
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 care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Gel-one injection (J7326) provided on October 19, 2021. 
 
You asked the Plan to pay for the Gel-one injection (J7326). You say that the attached records support the 
service, and the claim should be reconsidered. The Plan denied your request. The Plan says the records do not 
support the number of units 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 J7326 is hyaluronan or derivative, gel-one, for intra-
articular injection, per dose. 
 
  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 Gel-one injection (J7326). Our reviewer says that the 
documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer found that 
the procedure report documents the right knee was injected with 1 syringe of Gel-one. Therefore, two units of 
CPT code J7326 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 Gel-one injection (J7326) have not been met. Therefore, we decided that the 
Plan does not have to pay for the Gel-one injection (J7326) provided on October 19, 2021.