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

 
We decided that the Plan does not have to pre-approve Lidocaine 5% patches. 
 
You asked the Plan to pre-approve Lidocaine patches. You say that the medical records provided support the 
necessity of the requested services in dispute. The Plan denied your request. The Plan says this medication does 
not fall under Part B coverage and the enrollee does not have pharmacy (drug) benefits under the Plan. 
 
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 Lidocaine 5% patches.  
 
Benefits for Lidocaine patches 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH services are medically 
necessary. The Plan denied your request. The Plan says that the admission to a LTACH is not medically 
necessary. 
 
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 that the record indicates that the enrollee remains acutely ill and requires acute care 
services. The enrollee continues to receive acute care services, and these have not been denied. The medical 
record does not indicate that the enrollee requires services that she is not currently receiving but that would be 
available at the LTACH facility. The elements of the coverage rules are not satisfied.  
 
 
 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 LTACH services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan of the brain 
(78608). 
 
You asked the Plan to pre-approve a PET scan of the brain. You say that the service is medically necessary. 
The Plan denied your request. The Plan says the enrollee does not meet the diagnostic criteria of both 
Alzheimer's disease and frontotemporal dementia. There is no indication that the exam is being requested in the 
context of a clinical trial. 
 
The Plan follows Medicare rules. Medicare rules say that an FDG PET scan is only covered when there is a 
need to separate a differential diagnosis of frontotemporal dementia and Alzheimers disease. 
 
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 PET scan of the brain. Our reviewer 
says that the requested service is not medically necessary. Our physician reviewer found the enrollee was not 
noted to have dementia. Rather, the enrollee is suspected of possibly having MSA (multiple system atrophy). 
This is not a condition for which the NCD supports the use/provision of a PET/computed tomography (CT) 
scan of the brain. Consequently, this request cannot be said to meet the NCD criteria for coverage. 
 
   
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 PET scan of the brain have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a positron emission tomography (PET) scan of the brain (78608).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cooled Radiofrequency Ablation (RFA) (64635 and 
64636). 
 
You asked the Plan to pre-approve a cooled RFA. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that non-thermal modalities for facet joint denervation 
including chemical, low-grade thermal energy (less than 80 degrees Celsius), laser neurolysis, and cryoablation 
is considered not medically necessary or reasonable. 
 
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 cooled RFA. Our reviewer says that 
this service is not covered. Our physician reviewer found the requested service is considered to be cooled 
Radiofrequency Ablations (RFA), which is not considered 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 a cooled RFA have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a cooled Radiofrequency Ablation (RFA) (64635 and 64636).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a tier exception for Yupelri. 
 
You asked the Plan to pre-approve a tier exception for Yupelri. You say that the exception is needed. The Plan 
denied your request. The Plan says the items do not qualify for tier exceptions. 
 
The Plan must follow Medicare rules. Medicare rules say that tiered cost-sharing means a process of grouping 
Part D drugs into different cost sharing levels within a Part D sponsor's formulary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a tier exception for Yupelri have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a tier exception for Yupelri.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health aide services. 
 
You asked the Plan to pre-approve the aide services. You say that you need assistance at home. The Plan 
denied your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
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 aide services. Our reviewer says 
that the services are not medically reasonable and necessary. Our physician reviewer found that you do not 
have documented skilled nursing or skilled therapy needs. As such, home health services, including associated 
home health aide services, are not medically necessary or reasonable. 
 
 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 aide services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve home health aide services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing (G0480) and validity testing billed with code 
83789 for date(s) of service August 3, 2022. 
 You asked the Plan to pay for codes 83789 and G0480. You say that this service is medically necessary and 
should be paid. The Plan denied your request. The Plan says the billed services are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. Medicare rules also say that 
providers must report services correctly. Providers must report services with the appropriate CPT code. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. 
 
In this case, we have confirmed that code G0480 is a column II code to column I code G0481 with a modifier 
indicator of 0. The column II code is therefore not payable. 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 drug testing 
(G0480) and validity testing billed with code 83789 for date(s) of service August 3, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76775 billed for date of service February 23, 
2022. 
 
You asked the Plan to pay for procedure code 76775. You say that this service is supported as billed. The Plan 
denied your request. The Plan says payment for code 76775 is bundled into payment for code 76706. 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 76775 
is a column II code to column I code 76706. 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 76775 billed for date of service February 23, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for services provided on February 22, 2022, billed with codes 
75625, 37252, and 37253. 
 
You asked the Plan to pay for codes 75625, 37252, and 37253. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation. 
 
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 75625 is aortography, abdominal, by serialography, 
radiological supervision and interpretation. 
 
The CPT Code Manual definition of code 37252 is intravascular ultrasound (noncoronary vessel) during 
diagnostic evaluation and/or therapeutic intervention, including radiological supervision and interpretation; 
initial noncoronary vessel (List separately in addition to code for primary procedure). 
 
 The CPT Code Manual definition of code37253 is intravascular ultrasound (noncoronary vessel) during 
diagnostic evaluation and/or therapeutic intervention, including radiological supervision and interpretation; 
each additional noncoronary vessel (List separately in addition to code for primary procedure). 
 
We find that CPT codes 75625, 37252, and 37253 are not supported in the medical record. Specifically, the 
operative report did not include documentation of radiological supervision and interpretation of an abdominal 
aortography by serialography; therefore, code 75625 cannot be verified. 
 
The operative report did not include documentation of intravascular ultrasound (noncoronary vessel) during 
diagnostic evaluation and/or therapeutic intervention, including radiological supervision and interpretation, for 
the initial noncoronary vessel (listed separately in addition to code for primary procedure); therefore, code 
37252 cannot be verified. 
 
The operative report did not include documentation of intravascular ultrasound (noncoronary vessel) during 
diagnostic evaluation and/or therapeutic intervention, including radiological supervision and interpretation, for 
each additional noncoronary vessel (listed separately in addition to code for primary procedure); therefore, 
code 37253 cannot be verified. 
 
Based on this information, we decided that Medicare rules for coverage of codes 75625, 37252, and 37253 
have not been met. Therefore, we decided that the Plan does not have to pay for services provided on February 
22, 2022, billed with codes 75625, 37252, and 37253.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the transcatheter mitral valve repair (TMVR), also 
known as, transcatheter edge-to-edge repair (TEER) of the mitral valve. 
 
You asked the Plan to pre-approve the transcatheter mitral valve repair (TMVR), also known as, transcatheter 
edge-to-edge repair (TEER) of the mitral valve. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet coverage criteria. 
 
The Plan follows Medicare rules. Medicare rules say that Medicare covers transcatheter edge-to-edge repair 
(TEER) of the mitral valve for the treatment of symptomatic moderate-to-severe or severe functional mitral 
regurgitation (MR) when the patient remains symptomatic despite stable doses of maximally tolerated 
guideline-directed medical therapy (GDMT) plus cardiac resynchronization therapy, if appropriate. 
 
   
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 transcatheter mitral valve repair 
(TMVR), also known as, transcatheter edge-to-edge repair (TEER) of the mitral valve. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found at issue is the medical appropriateness 
and necessity of transcatheter mitral valve replacement (TMVR) in this enrollee with a stenotic mitral valve 
prosthesis. Guidelines are not consistent with this indication for TMVR. The documentation is inadequate to 
confirm fulfillment of published CMS guidelines for TMVR. As a result, at this time TMVR would not be 
considered medically reasonable 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 the transcatheter mitral valve repair (TMVR), also known as, transcatheter 
edge-to-edge repair (TEER) of the mitral valve. have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the transcatheter mitral valve repair (TMVR), also known as, transcatheter edge-to-
edge repair (TEER) of the mitral valve.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Allograft services. 
 
You asked the Plan to pre-approve allograft services. You say that the records provided support the need for the 
requested services.  
 The Plan denied your request. The Plan says allograft-based products that are cell based that is mesenchymal 
stem cells are unproven and not medically necessary for the enhancement of spinal fusion and bone healing due 
to insufficient evidence of efficacy and/or safety. 
 
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 allograft services. Our reviewer says 
that allograft services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found stem cell allograft products remain experimental in spinal surgery. Conventional allograft chips 
or iliac crest bone graft is the gold standard. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of allograft services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Allograft services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection (ESI). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that an ESI is covered when specific criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has a history of chronic 
lumbar pain due to lumbar spinal stenosis with radiculopathy. She has been treated with medical and physical 
therapy. There is no documentation of the level to be injected or the response to conservative therapy. The 
criteria for coverage are not met and the ESI is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an epidural steroid injection (ESI).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM) and 
supplies (K0553, K0554). 
 
You asked the Plan to pre-approve a CGM and supplies. You say that the requested CGM and supplies are 
necessary, and you are requesting reconsideration. Medical records have been submitted. The Plan denied your 
request. The Plan says the enrollee's records show he does not have either an insulin pump or multiple daily 
administrations of insulin. The enrollee is prescribed insulin only twice a day. The enrollee does not meet 
criteria for approval of the CGM and supplies. 
 
 
 
 
 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 CGM and 
supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a therapeutic 
continuous glucose monitor (CGM) and supplies (K0553, K0554).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service October 4, 
2022. 
 
You asked the Plan to pay for procedure code 76641. You say that multiple procedures were performed on this 
date. 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 76641 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 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 October 4, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee meets the full criteria for an inpatient 
acute rehabilitation stay, which is needed for rehabilitation to maximize her potential to return to her previous 
level of independence. The Plan denied your request. The Plan says the IRF care is not medically necessary, 
and the enrollee's needs can be met at a lower level of care such as a skilled nursing facility, home with home 
health services or home with outpatient therapy. 
 
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 in this case, the complexity of the enrollees nursing, medical and rehabilitation 
needs do not require an acute rehab 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, at an intensive rehabilitation therapy program. There is not a reasonable expectation that 
this individual will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an inpatient rehabilitation facility. 
 
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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve an office visit. You say that you had a cat scan showing metastatic disease 
in the liver. The Plan denied your request. The Plan says your records received do not indicate that you have an 
emergent or urgent medical condition or are in need of specialized service(s) that are not available in the 
network. There are in-network provider(s) within a reasonable distance from your location that can provide this 
service or item. 
 
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 to be provided by an out-of-network (OON) provider.