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

 
We decided that the Plan does not have to pre-approve Aranesp (J0881). 
 
You asked the Plan to pre-approve Aranesp. You say that the requested drug is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee has not tried and failed the preferred drugs, 
Procrit and Retacrit. 
 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 Aranesp. 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 required drugs. The reviewer also found that there is no 
indication that the plan's required drugs would likely be less effective and/or likely have adverse effects for the 
enrollee. 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 Aranesp have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Aranesp (J0881).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 continuous glucose monitor (CGM) 
sensor. 
 
You asked the Plan to pre-approve a Freestyle Libre 2 CGM sensor. You say that the enrollee needs the 
requested CGM due to an underlying condition with diabetic amyotrophy. The Plan denied your request. The 
Plan says the enrollee does not meet criteria for approval of the requested CGM sensor. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections or require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of a Freestyle 
Libre 2 CGM sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Freestyle Libre 2 continuous glucose monitor (CGM) sensor.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you are not ready to be safely discharged home, 
your physician is recommending a SNF. The Plan denied your request. The Plan says the request is not 
medically necessary. 
 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 that you do not have skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have skilled therapy needs that require the 
specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require daily skilled 
nursing and/or skilled therapy on an inpatient basis in a 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 SNF care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on February 23, 2022, to 
March 2, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
claim was billed correctly and should be paid. The Plan denied your request. The Plan says documentation does 
not support the billed code. 
 
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 principal diagnosis A41.59, described as other 
gram-negative sepsis. 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 documentation does not support the billed code. 
Our physician reviewer found the documentation does not consistently and completely support the assigned 
principal diagnosis code billed.  
 
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 February 23, 2022, to March 2, 2022, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested IRF services are necessary because the 
level of care will help the enrollee recover more quickly. The Plan denied your request. The Plan says the 
enrollee does not meet Medicare criteria for an IRF admission. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollees nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee may have a need for physical 
therapy and/or occupational therapy, there is no documented need for intensive rehabilitation services. 
Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that 
the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMs device. 
 
You asked the Plan to pre-approve a CardioMEMs device. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a CardioMEMs device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found 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 this enrollees 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 a CardioMEMs device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMs device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a percutaneous implantation of neurostimulator 
electrode array; peripheral nerve (excludes sacral nerve) (64555). 
 
You asked the Plan to pre-approve Percutaneous Electrical Nerve Stimulation. You say that you disagree with 
the denial and have submitted additional information. The Plan denied your request. The Plan says the request 
does not meet the Medicare or health plan coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Percutaneous Electrical Nerve 
Stimulation. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the enrollee has chronic low back pain after multi-level 
laminectomy. She has had epidural steroid injections and trigger point injections. This approach is considered 
experimental for the treatment of low back pain. Therefore, the request is deemed 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 Percutaneous Electrical Nerve Stimulation have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a percutaneous implantation of neurostimulator electrode 
array; peripheral nerve (excludes sacral nerve) (64555).
Appeal type: Imaging
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by code 0042T. We decided that the Plan does 
not have to pay for the services described by code 70450.  
 
You asked the Plan to pay for the radiological services provided on October 20, 2022, billed with codes 70450 
and 0042T. You say that these services were billed correctly and should be paid. The Plan says that code 70450 
is bundled in payment for code 70496. Also, code 0042T cannot be paid as it was provided out of network 
without authorization. 
 
We decided that the Plan has to pay for the services described by code 0042T.  
 
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. We reviewed the Plans denial rationale for this code, and we find that the 
rationale is not valid. These services were provided by an interpreting radiologist who would not have the 
opportunity to obtain authorization. As no other valid rationale was provided, we find that the denial of 
payment is not substantiated. Therefore, we decided that the Plan has to pay for the services described by code 
0042T.  
 
We also decided that the Plan does not have to pay for the services described by code 70450. 
 
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 70450 
is a Column 2 code to Column 1 code 70496. 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 described by code 70450. 
 
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 pre-approve a catheter placement in coronary artery(s) for coronary 
angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and 
interpretation; with left heart catheterization including intraprocedural injection(s) for left ventriculography 
(93458). 
 
You asked the Plan to pre-approve a left heart catheterization. You say that you disagree with the denial. The 
Plan denied your request. The Plan says a left heart catheterization is not recommended unless there is evidence 
of at least mild ischemia on imaging or significant obstructive coronary artery disease on 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 a left heart catheterization. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found at issue is the medical appropriateness and necessity for performance of 
cardiac catheterization. The enrollee has a history of cardiac workup for her chest pains in 2022, including two 
stress tests, one a radionuclide stress test and the other a stress echocardiogram. Both were negative for 
ischemia. Guidelines do not support a need for invasive cardiac catheterization in this setting. As a result, at 
this time cardiac catheterization would not be considered medically appropriate and necessary in this 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 a left heart catheterization have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a catheter placement in coronary artery(s) for coronary angiography, 
including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with 
left heart catheterization including intraprocedural injection(s) for left ventriculography (93458).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing coded G0483 provided on August 17, 2022. 
 
You asked the Plan to pay for the drug testing. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services billed are not supported. 
 
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 G0483 is drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and 
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or 
more drug class(es), including metabolite(s) if performed. 
 We find that CPT code G0483 is not supported in the medical record. Specifically, the documentation does not 
support that 22 or more drug classes were performed. Based on this information, we decided that Medicare 
rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to 
pay for the drug testing coded G0483 provided on August 17, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lens for the left eye due to corneal neovascularization, 
due to unspecified corneal neovascularization, left eye. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says there are more definitive treatments that include corneal transplantation. 
 
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 the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that scleral contact lens is not considered a standard treatment for corneal neovascularization. Medical 
treatments include topical steroids, anti-VEGF medications (e.g., Avastin), treatment of the patient's underlying 
neurotrophic cornea (e.g, Oxervate, lubrication, punctal plugs). Surgical interventions can include laser 
ablation, photodynamic therapy, and cauterization. Lastly, corneal transplantation is an option for visually 
significant corneal opacities.  
 
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 lens for the left eye due to corneal neovascularization, due to unspecified corneal 
neovascularization, left eye.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that medical records were submitted to support 
the reconsideration of the denied home ventilator. The Plan denied your request. The Plan says based on the 
clinical information submitted, there is no documentation to support the need for the ventilator versus a CPAP 
or BIPAP. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the record indicates that the enrollee 
has chronic respiratory failure from chronic obstructive pulmonary disease. The provided primary source 
documentation does not contain sufficient detailed information in the medical record to justify the treatment 
selected. The enrollee could be treated with a BiPAP machine with AVAPS capability. The plan has indicated 
coverage for such a device is available upon request. The elements of the coverage criteria are not satisfied. 
The requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on March 27, 2022, at 
the Diagnosis Related Group (DRG) originally billed. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
claim was billed correctly and should be paid, The Plan denied your request. The Plan says documentation does 
not support the billed code. 
 
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 principal diagnosis code A41.9, described as 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 billed 
code Our physician reviewer found that the enrollee is a 36-year-old female with a past medical history 
including multiple sclerosis who presented to the hospital with fever and weakness. At the time of presentation, 
her vital signs were stable. The laboratory studies showed an elevated white blood count with normal renal 
function and platelets. She was treated for a presumed urinary tract infection and improved. There was no 
evidence of life-threatening organ dysfunction due to dysregulated host response to an infection or persistent 
hemodynamic instability.  
 
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 March 27, 2022, at the Diagnosis Related Group (DRG) originally 
billed.