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

 
We decided that the Plan does not have to pre-approve Prolia (J0897). 
 
You asked the Plan to pre-approve Prolia. You say that the enrollee has previously been treated with 
alendronate for over five years. You say that you feel the enrollee should now be managed on Prolia. The Plan 
denied your request. The Plan says the documentation submitted do not indicate contraindications, allergy or a 
trial and/or failure of the preferred drug. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Prolia. Our reviewer says that the step 
therapy criteria have not been met. Our physician reviewer found the provided records do not indicate that the 
enrollee has tried and failed the plan's preferred drugs. The record does not indicate that the enrollee has a 
contraindication to or would have an adverse effect from the plan's preferred drugs. Therefore, the reviewer 
found that the step therapy criteria have not been met. 
 
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 (J0897).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the elbow orthosis provided on October 18, 2022. 
 
You asked the Plan to pay for the elbow orthosis. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the documentation does not support the code billed. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. Review of the file shows that the medical records provided to not support the need for the item at 
issue. There is no documentation to support the enrollee had a diagnosis/condition that would require the elbow 
orthosis provided.  The record shows that the Plan made several attempts to obtain the necessary documentation without success. 
Therefore, we decided that the Plan does not have to pay for the elbow orthosis provided on October 18, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gene panel testing provided on August 17, 2022. 
 
You asked the Plan to pay for the panel testing. The Plan denied your request. The Plan says one code must be 
submitted for the testing. 
 
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 find that the gene panel was not billed with a single code as required. Based on this information, we 
decided that Medicare rules for coverage of the panel testing have not been met. Therefore, we decided that the 
Plan does not have to pay for the gene panel testing provided on August 17, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on October 07, 2020, 
billed with diagnosis code A41.9. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that primary 
diagnosis code A41.9 is supported by the records. The Plan denied your request. The Plan says the 
documentation submitted does not support primary diagnosis of A41.9. 
 
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 primary diagnosis code A41.9-Sepsis, Unspecified 
Organism. 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 primary diagnosis of 
A41.9, Sepsis. Our physician reviewer found there was no documentation of an arterial blood gas results found 
in the records that validate the member having a P/F ratio that was less than 400. There is insufficient evidence 
that use of peripheral oxygen saturation (SpO2) readings is reliable in calculating a members P/F ratio. The 
member had a Glasgow Coma Score of 15, platelets were never below 150, a total bilirubin level at 0.8 with a 
lactic acid level of 1.0. There was no documentation of hypotension as evidenced by a MAP less than 70. There 
was no documentation of decreased or insufficient urinary output. The member's serum creatinine on admission 
was at 1.2. However, after study and after initial hydration, the member's repeat serum creatinine level was 
0.90. There was no clinical or laboratory evidence of sepsis. Therefore, diagnosis code A41.9-Sepsis, 
unspecified Organism is not the appropriate primary diagnosis code.  
 
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 07, 2020, billed with diagnosis code A41.9.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76642 billed for date of service August 25, 
2022. 
 
You asked the Plan to pay for procedure code 76642. You say that the claim was billed correctly and should be 
paid. 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 76642 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 76642 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 76642 billed for date of 
service August 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lumbar laminectomy and fusion with allograft utilizing 
Grafton OrthoBlend (20930, 20936, 22612, 22614, 22840, 63047). 
 
You asked the Plan to pre-approve lumbar laminectomy and fusion. You say that you have been dealing with 
back pain since 1999. Your back pain has been treated by numerous doctors over the past nearly 25 years and 
you still experience severe pain in your back that at times radiates down through your legs. You have 
undergone numerous cycles of epidural injections series and had little to no relief. This surgery is your last 
hope to getting relief of pain. The Plan denied your request. The Plan says the requested service is not covered 
by Medicare or the health plan. 
 
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 lumbar laminectomy and fusion. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the criteria for fusion is not met. There is no documented spinal instability, 
lesion, or fracture. Multilevel fusion for degenerative back pain is not more effective than conservative 
measures. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of lumbar laminectomy and fusion have not been met. Therefore, we decided that 
the Plan does not have to pre-approve lumbar laminectomy and fusion with allograft utilizing Grafton 
OrthoBlend (20930, 20936, 22612, 22614, 22840, 63047).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says the 
services you need could be provided in another setting, an acute rehabilitation facility, skilled nursing facility, 
nursing facility, outpatient setting or home care. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no documentation provided indicating medical necessity for admission to a 
LTACH, the enrollee is receiving appropriate care at the present acute care hospital and does not require 
services at the LTACH that are not available at the current acute care hospital. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 86077 billed for date of service July 11, 
2022. 
 
You asked the Plan to pay for procedure code 86077. You say that this service was medically necessary. 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 cannot be paid when the MAI value is 2.   
In this case, the MUE for CPT code 86077 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 86077 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 86077 billed for date of service July 11, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam therapy. 
 
You asked the Plan to pre-approve proton beam therapy. You say that this is medically necessary. The Plan 
denied your request. The Plan says the requested service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve proton beam therapy. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is insufficient prospective, long-term clinical data available to determine 
whether proton beam radiation therapy for prostate cancer is superior, inferior, or equivalent to external beam 
radiation therapy, intensity-modulated radiation therapy, or brachytherapy with regards to safety and efficacy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of proton beam therapy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve proton beam therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 36410 billed for date of service October 6, 
2022. 
 
You asked the Plan to pay for procedure code 36410. You say that this service was medically necessary. The 
Plan denied your request. The Plan says payment for code 36410 is bundled into payment for code 00640.  
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 36410 
is a column II code to column I code 00640. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 36410 billed for date of service October 6, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lead neurostimulator (C1778 x 2), injection (64555 x 2), 
and implantable neurostimulator electrode (L8680 x 2). 
 
You asked the Plan to pre-approve implantation of a Sprint peripheral nerve stimulator (PNS). You say that the 
requested treatment is medically necessary for the enrollee. The Plan denied your request. The Plan says the 
requested treatment 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 implantation of a Sprint peripheral 
nerve stimulator (PNS). Our reviewer says that the requested implantation of a Sprint PNS is not considered 
medically reasonable and necessary in this case. Our physician reviewer found the requested procedure is 
considered experimental and investigational for the enrollee's diagnosis. Therefore, the requested procedure 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 implantation of a Sprint peripheral nerve stimulator (PNS) have not been met. 
Therefore, we decided that the Plan does not have to pre-approve lead neurostimulator (C1778 x 2), injection 
(64555 x 2), and implantable neurostimulator electrode (L8680 x 2).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture services (97810, 97811) provided on July 
12, 2022. 
 
You asked the Plan to pay for the acupuncture services. You say that the enrollee has acupuncture benefits. The 
Plan denied your request. The Plan says acupuncturists are not able to be reimbursed by Medicare.  
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the 
Plans rules apply in this case.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the provider in this case is an acupuncturist. 
Acupuncturists are not able to receive payment from Medicare. Therefore, we decided that the Plan does not 
have to pay for the acupuncture services (97810, 97811) provided on July 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI). 
 
You asked the Plan to pre-approve SSBCI benefits. You say that you received an over-the-counter (OTC) card, 
and would like to verify if you are eligible for the SSBCI benefits. You also say that you have arthritis and 
some other conditions. The Plan denied your request. The Plan says you do not present the health conditions 
that make you eligible for these benefits. 
 
The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for 
enrollees with an eligible chronic condition.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI benefits have not been met. Specifically, we have confirmed that you do not have one of 
the eligible conditions listed in the Evidence of Coverage. Therefore, we decided that the Plan does not have to 
pre-approve special supplemental benefits for the chronically ill (SSBCI).
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for the home health services provided July 25, 2022, to July 28, 
2022. 
 
You asked the Plan to pay for the home health services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the type of bill on the claim is invalid. 
 
The Plan follows Medicare rules. The rules say that home health claims must be submitted with correct type of 
bill. 
 
Review of the file shows that the claim was billed with an invalid type of bill for this home health provider. As 
the claim was not billed with a correct type of bill, no payment can be made on this claim. Therefore, we 
decided that the Plan does not have to pay for the home health services provided July 25, 2022, to July 28, 
2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vabysmo (J2777) and intravitreal injection (67028). 
 
You asked the Plan to pre-approve Vabysmo injection. You say that the enrollee has been on Eylea since 
November 2019. The Plan denied your request. The Plan says the enrollee has not tried and failed the preferred 
drug, Avastin. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Vabysmo injection. Our reviewer says 
that the step therapy criteria have not been met. Our physician reviewer found the provided documentation does 
not indicate that the enrollee has tried and failed the preferred drug, Avastin. The reviewer also found that the 
documentation does not support that Avastin would likely be less effective, and/or would likely have adverse 
effects for the enrollee in this case. Therefore, the reviewer found that the step therapy criteria have not been 
met. 
 
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 injection have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Vabysmo (J2777) and intravitreal injection (67028).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ultrasound guided radiation therapy (G6001). 
 
You asked the Plan to pre-approve ultrasound guided radiation therapy. You say that IGRT increased the 
efficacy of superficial radiation therapy based on studies that have been done. The Plan denied your request. 
The Plan says guidelines for squamous cell skin cancer do not support the use of ultrasound images as the 
deciding factor for RT dose prescription decisions. 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 ultrasound guided radiation therapy. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found IGRT is a means to improve set-up accuracy. IGRT uses daily image 
guidance to help localize the target to minimize normal tissue dosing. Specifically, IGRT allows accuracy of 
treatment delivery, so when generating a planning target margin, the margins can be reduced, and thus allow 
reduction in the volume of normal tissues exposed to radiation. Usually, IGRT is used when critical structures 
are abutting or in close proximity to the target that is being treated to high doses. This situation does not apply 
to this enrollee for which the target lesion can be seen on the skin to assist in daily set up. When treating skin 
cancers, there is generally not a need for IGRT unless deep structures are being treated. Certainly, using 
ultrasound on a daily basis is not unreasonable to offer but not necessary. The device itself is FDA approved 
for use with ultrasound though that in and of itself does not mean that daily imaging is necessary but simply 
that the device was designed to incorporate this functionality. Therefore, to bill for daily simple simulations 
and/or IGRT for a technology for which need has not been established by published data or supported by 
consensus guidelines (many of which recommend against treatment with these devices in general) is not 
necessary. The decision is unfavorable as billing for daily IGRT would not be furnished in accordance with 
accepted standards of medical practice. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ultrasound guided radiation therapy have not been met. Therefore, we decided 
that the Plan does not have to pre-approve ultrasound guided radiation therapy (G6001).