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

 
We decided that the Plan does not have to pre-approve Vabysmo (J2777), every four weeks for two additional 
months. 
 
You asked the Plan to pre-approve Vabysmo, every four weeks for two additional months. You say that the 
enrollee has had prior insufficient response with Avastin and Eylea at 4-week intervals. You say that it is best 
for the enrollee to continue Vabysmo injection every 4 weeks for 6 months. The Plan denied your request. The 
Plan says the requested duration is not medically necessary. 
 
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 Vabysmo, every four weeks for two 
additional months. Our reviewer says that the request for an additional two months to treatment with Vabysmo 
is not medically necessary. Our physician reviewer found the provided documentation does not support that the need of two additional months of this drug is medically necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vabysmo, every four weeks for two additional months have not been met. 
Therefore, we decided that the Plan does not have to pre-approve Vabysmo (J2777), every four weeks for two 
additional months.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the swallow function x-ray with contrast (74230), and upper 
gastrointestinal tract x-ray with contrast (74240) provided on August 31, 2022. 
 
You asked the Plan to pay for the x-rays with contrast. You say that the enrollee was consulted in a skilled 
nursing facility. You also say that these services should be paid. The Plan denied your request. The Plan says 
these services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that the scope of the covered portable x-ray benefit is 
defined as chest and abdominal films which do not involve the use of contrast media.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the x-rays with contrast have not been met. Specifically, chest and abdominal x-rays with contrast 
are not coverable. Therefore, we decided that the Plan does not have to pay for the swallow function x-ray with 
contrast (74230), and upper gastrointestinal tract x-ray with contrast (74240) provided on August 31, 2022.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve ablation of malignant prostate tissue, transrectal, with high 
intensity-focused ultrasound (HIFU), including ultrasound guidance (CPT code 55880). 
 
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says that the service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 service. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found numerous clinical studies have demonstrated treatment efficacy that is comparable to surgery or 
radiation, but with a much lower risk of side effects such as impotence, incontinence and bowel injury. 
 
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 service have been met. Therefore, we decided that the Plan has to pre-
approve ablation of malignant prostate tissue, transrectal, with high intensity-focused ultrasound (HIFU), 
including ultrasound guidance (CPT code 55880).  
 
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) care. 
 
You asked the Plan to pre-approve SNF care. You say that the services are medically necessary for the enrollee 
to receive the proper level of care. The Plan denied your request. The Plan says the enrollee's current level of 
functioning does not require daily skilled therapy that can only be provide on an inpatient basis in a SNF. 
 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 the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee skilled therapy on an inpatient basis in a skilled nursing facility (SNF) 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 care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection between wheelchair controller 
and two or more power seating system motors (E2311), a harness (E2313) and an expandable controller 
(E2377). 
 
You asked the Plan to pre-approve wheelchair accessories. You say that the decision was incorrect since the 
enrollee does meet medical necessity based on Medicare guidelines for the tilt and recline seating system. The 
Plan denied your request. The Plan says although there are three requested power options, there is not a 
medical need to control these power options through the joystick. The enrollee is noted to be independent with 
feeding and dressing. The enrollee's upper limb strength and function are adequate for her to be able to control 
the power options using their own switches which are included in the allowance of these power options. 
 
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 wheelchair accessories. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found provided records document that the enrollee is independent with eating and dressing 
thus indicating she has adequate upper extremity strength and function to operate the wheelchair's power 
options with their own switches. The available medical records do not support medical necessity of the 
equipment as defined by Medicare criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of wheelchair accessories have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an electronic connection between wheelchair controller and two or more power 
seating system motors (E2311), a harness (E2313) and an expandable controller (E2377).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for excision, tumor, soft tissue of thigh or knee area, 
subcutaneous; 3 cm or greater provided to the enrollee on July 6, 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 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 27337 is "Excision, tumor, soft tissue of thigh or knee 
area, subcutaneous; 3 cm or greater." 
 
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 procedure in detail cites 
removing an aggregate of 15cm of mass." The documentation indicates that in total 15cm of mass was 
removed/excised. There is no corroboration of a single subcutaneous mass of 3cm or greater. Therefore, 
records do not support that CPT 27337: excision; tumor, soft tissue of thigh or knee area, subcutaneous, 3cm or greater was rendered 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 excision, tumor, soft tissue of thigh or knee area, subcutaneous; 3 cm or greater provided to the 
enrollee on July 6, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on October 10, 2021, 
through October 12, 2021, and billed with diagnosis code G93.41. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that 
secondary diagnosis G93.41 is supported by the records. The Plan denied your request. The Plan says the 
documentation submitted does not support secondary diagnosis of G93.41. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with secondary diagnosis code G93.41 - Metabolic 
encephalopathy. 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 inpatient hospital 
services at the DRG originally billed. Our reviewer says that the documentation does not support the secondary 
diagnosis of G93.41, Metabolic encephalopathy. Our physician reviewer found the member's first evaluation by 
the Infectious Disease consultant was described as having been lucid, alert, and awake and interactive, with 
fluent speech. The Infectious Disease consultant did not personally encounter the member in a confused or 
altered state. The member's mental status was at baseline on presentation and throughout the hospital stay, 
therefore diagnosis code G93.41- Metabolic encephalopathy is not the appropriate secondary diagnosis.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on October 10, 2021, through October 12, 2021, and billed with 
diagnosis code G93.41.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the morphine sulfate capsule. 
 
You asked the Plan to pre-approve the morphine sulfate capsule. The Plan denied your request. 
 
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 the morphine sulfate 
capsule.  
 
Benefits for the morphine sulfate capsule 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: Favorable

 
We decided that the Plan has to pay for procedure codes 37214, 37224, 37228 provided to the enrollee on May 
12, 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 
the denied codes is: 
 
CPT 37214: 
 
Transcatheter therapy, arterial or venous infusion for thrombolysis other than coronary, any method, including 
radiological supervision and interpretation, continued treatment on subsequent day during course of 
thrombolytic therapy, including follow-up catheter contrast injection, position change, or exchange, when 
performed; cessation of thrombolysis including removal of catheter and vessel closure by any method 
 
CPT 37224: 
 
Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with 
transluminal angioplasty 
 
CPT 37228: 
 
Revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial vessel; with 
transluminal angioplasty 
 
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 CPT 37214 codes for cessation of 
thrombolysis. The patient had undergone 24 hours of thrombolysis, and this was stopped during the procedure 
in question. This was associated with diagnostic imaging through the catheter as well as other interventions. In 
terms of CPT 37224, this codes for femoral-popliteal angioplasty; there is satisfactory documentation that 
angioplasty of the superficial femoral and popliteal artery was performed with a 5 mm balloon. In terms of CPT 
37228, this codes for tibial artery angioplasty; there is satisfactory documentation that angioplasty of the 
posterior tibial artery was performed with a 3 mm balloon. The documentation includes findings pre-and post-
intervention. 
 
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 codes 37214, 37224, 37228 provided to the enrollee on May 12, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a patient domiciliary, rest home, or custodial care visit 
provided on July 25, 2022, by an out-of-network provider. 
 
You asked the Plan to pay for the patient domiciliary, rest home, or custodial care visit. The Plan denied your 
request. The Plan says the beneficiary must use network providers unless prior authorization is granted. 
 
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 a patient domiciliary, rest home, or custodial care visit provided 
on July 25, 2022, by an out-of-network provider.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for muscle or tendon transfer, any type, upper arm or elbow, single 
provided to the enrollee on August 15, 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 
CPT 24301 is "Muscle or tendon transfer, any type, upper arm or elbow, single (excluding 24320-24331)." 
 
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 was being treated for 
primary osteoarthritis of the left shoulder. She underwent a left reverse total shoulder arthroplasty; anterior and 
posterior capsule contracture release; and single muscle transfer of the long head of the biceps to the pectoralis 
major on 8/15/22. The procedure description cites the fascia was split into the rotator interval. The retained 
biceps was then transferred to the pectoralis major with a total of 3 figure-of-8 #2 Ethibond sutures. This 
concluded the transfer of the biceps tendon to the pectoralis major. Therefore, the records do support that CPT 
24301 was rendered 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 been met. Therefore, we decided that the Plan has to pay for 
muscle or tendon transfer, any type, upper arm or elbow, single provided to the enrollee on August 15, 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 Prolia injection.

You asked the Plan to pre-approve Prolia. You say that you disagree with the Plan's denial. The Plan denied your request. The Plan says the requested drug is not medically necessary.

The Plan follows Medicare rules. Medicare rules say that Prolia is only covered for certain indications.

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 Prolia. 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 diagnoses of age-related osteoporosis without current pathological fracture and chronic kidney disease. Bone density testing provided in this case is diagnostic of osteopenia with a left femoral neck T-score of -1.6 from 01/03/2020. No more recent bone density testing is provided. Although guidelines recommend treatment for osteopenia with high risk for fracture, Medicare guidelines as detailed above do not authorize use of Prolia in this instance. Therefore, the enrollee does not meet criteria for the requested drug.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia injection.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service August 30, 
2022. 
 
You asked the Plan to pay for procedure code 76641. You say that this claim denied as a duplicate in error. The 
Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Specifically, you billed one line item of this code with the LT modifier and one line 
item of this code with the RT modifier instead of billing one line item with the bilateral modifier as is required. 
Based on this information, we decided that Medicare rules for coverage of procedure code 76641 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 76641 billed for date of 
service August 30, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is considered 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 procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that this procedure is experimental for back pain. 
 
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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Intracept procedure.