Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve left knee arthroscopy with lateral release and possible 
partial medial meniscectomy (CPT code(s): 29873, 29881, and 29880) to be provided by an out-of-network 
provider. 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says there are in-network provider's that can render the services. 
 
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 
left knee arthroscopy with lateral release and possible partial medial meniscectomy (CPT code(s): 29873, 
29881, and 29880) to be provided by an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cardiovascular risk assessment testing (81404 and 81406) 
provided on July 2, 2021. 
 
You asked the Plan to pay for the cardiovascular risk assessment testing. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says the enrollee's 
physician did not order the labs at issue. 
 
The Plan follows Medicare rules. The rules explicitly say that a physician order or clear intent to order specific 
lab services in the medical record, is required for Medicare-covered laboratory services.  
 
We looked at your request, the file and Medicare rules. Based on this information we determined that Medicare 
criteria for coverage have not been met. Specifically, the documentation submitted indicates that this testing 
was not ordered by the enrollee's treating physician. Therefore, we decided that the Plan does not have to pay 
for the cardiovascular risk assessment testing (81404 and 81406) provided on July 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat cervical 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 lumbago, 
acute lumbar radiculopathy, cervicalgia, cervical radicular pain, and chronic pain syndrome. She had a cervical 
ESI on December 6, 2021 and the pain relief was rated at 45 percent at the follow-up evaluation on December 
21, 2021. She had less than 50 percent pain relief from the first injection; therefore, the repeat cervical 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 a repeat cervical epidural steroid injection (ESI).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia billed for services provided on August 12, 
2021. 
 
You asked the Plan to pay for the billed services. You say that professional services of the attending 
anesthesiologist were billed. The Plan denied your request. The Plan says supporting documentation was not 
received. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  In this case, the CPT Code Manual definition of code 01922 is anesthesia for non-invasive imaging or radiation 
therapy. We find that CPT code 01922 is not supported in the medical record. Specifically, the records 
provided do not show that the enrollee received non-invasive imaging or radiation therapy on the date of 
service at issue. Based on this information, we decided that Medicare rules for coverage of the billed services 
have not been met. Therefore, we decided that the Plan does not have to pay for the anesthesia billed for 
services provided on August 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infectious agent detection by nucleic acid (DNA or RNA); 
severe acute respiratory syndrome coronavirus 2 (SARS-Co V-2) (Coronavirus) (U0003) and sales tax (S9999), 
provided on January 14, 2022. 
 
You asked the Plan to pay for the at home Covid-19 test and sales tax. You say that the item should be covered. 
The Plan denied your request. The Plan says this item is not listed in the members OTC catalog and is 
therefore not covered by the members plan. 
 
The Plan must follow Medicare rules. Medicare rules say that  MA plans may choose to offer some benefits to 
enrollees in addition to the covered Medicare Part A and Part B (and Part D, as applicable) benefits they are 
required to offer if the item or service also meets the criteria described in sections 30 and 40 of this chapter.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the at home Covid-19 test and sales tax have not been met. Therefore, we decided that the Plan 
does not have to pay for infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory 
syndrome coronavirus 2 (SARS-Co V-2) (Coronavirus) (U0003) and sales tax (S9999), provided on January 
14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on June 16, 2021. 
 
You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the 
services were billed with the incorrect place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the drug testing services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample 
was taken in a laboratory setting. Therefore, we decided that the Plan does not have to pay for the drug testing 
services provided on June 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoperative monitoring (G0453), provided on 
December 20, 2021. 
 
You asked the Plan to pay for the intraoperative monitoring. 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 Medicare covers services that are medically 
necessary. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the intraoperative monitoring. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found the member underwent TKA. 
IONM services were provided during the procedure.  This is not a type of procedure for which there is 
literature showing that IONM is safe and/or effective. That is to say, the literature does not demonstrate that 
there is a net benefit from the provision of IONM services during this type of procedure.  The use of IONM 
during this type of procedure is otherwise not one for which there is support within the LCD on this topic. 
 
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 intraoperative monitoring have not been met. Therefore, we decided that the 
Plan does not have to pay for the intraoperative monitoring (G0453), provided on December 20, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Bevacizumab (Mvasi) (CPT code Q5107). 
 
You asked the Plan to pre-approve the medication. You say that treatment with Mvasi in combination with 
other targeted therapies could significantly prolong this enrollee's life, while maximizing their quality of life. 
The Plan denied your request. The Plan says use of this drug bevacizumab (Mvasi) for recurrent metastatic 
pancreatic adenocarcinoma is not FDA approved. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the medication. Our physician reviewer 
found the requested use of Bevacizumab (Mvasi) is not FDA-approved for the enrollees diagnosis. The use is 
not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved 
medical journal.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Bevacizumab (Mvasi) (CPT code Q5107).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the office visits to be provided by an out-of-network 
provider. 
 
You asked the Plan to pre-approve the out-of-network services. You say that the request is to gain approval of 
follow-up office visits under continuity of care. The Plan denied your request. The Plan says the clinical 
information presented does not show that these services are for an emergency or cannot be provided by 
physicians, hospitals or providers who are in the Plan's network. 
 
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 provider at issue in this case is not a network provider with the Plan. 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 out-of-network services. Our physician reviewer found there was not an 
indication that there was a network deficiency for the provision of care in this case. The management of the 
enrollee's symptoms is otherwise largely symptomatic in nature, and there were no unique clinical factors presented to necessitate continued care with this specific provider. As such the request would not be 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 the out-of-network services have not been met.  
 
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 the out-of-network services. Therefore, we decided 
that the Plan does not have to pre-approve the office visits to be provided by an out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Dupixent injector pen. 
 
You asked the Plan to pre-approve self-administered drug. You say that you require this medication. The Plan 
denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not 
covered by Medicare Part B and the Plan does not administer your Medicare Part D prescription drug benefits. 
 
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 Dupixent injector pen.  
 
Benefits for self-administered drug 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS device (CPT code 33289). 
 
You asked the Plan to pre-approve the CardioMEMS device. You say that the service is medically necessary. 
The Plan denied your request. The Plan says the CardioMEMS device at this point should only be approved for 
patients enrolled in a clinical trial. The Plan states there is no indication that this enrollee is enrolled in a 
clinical trial of the device. 
 
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 CardioMEMS device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the CardioMEMS device was approved by the FDA in 2014 and consists of a sensor 
device placed in the pulmonary artery to allow measurement of pulmonary artery pressure in the management 
of patients with congestive heart failure (CHF). The clinical study on which FDA approval was based showed 
improved clinical outcomes and decreased hospitalizations in patients in whom the CardioMEMS system was implanted, reflecting a patient population with preserved ejection fraction and was somewhat limited in scope 
(1). Subsequent follow-up studies remain encouraging and suggest an improvement in heart failure symptoms 
with the use of the device (2). In addition, published expert opinion in the cardiology literature is supportive of 
the clinical usefulness of CardioMEMS. Nonetheless, 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 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 the CardioMEMS device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the CardioMEMS device (CPT code 33289).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the services you require to get stronger you can safely be received at a 
different setting. 
 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 services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that your condition does not meet 
Medicare criteria for SNF services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter (K0800). 
 
You asked the Plan to pre-approve the power scooter. You say that the power scooter is medically necessary. 
The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 power scooter. Our reviewer says 
that the power scooter is not medically necessary. Our physician reviewer found there is no documentation that 
the patient's mobility deficit cannot be helped by the use of a manual wheelchair.   
 
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 power scooter have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a power scooter (K0800).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex procedure. 
 
You asked the Plan to pre-approve Vertiflex. You say that the enrollee has failed conservative treatments and is 
a good candidate for Vertiflex. The Plan denied your request. The Plan says the denial of authorization for this 
service is correct, because Vertiflex is experimental/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 Vertiflex. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Vertiflex device is experimental, more research is needed to show its 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 Vertiflex have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Vertiflex procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous implantation of neurostimulator electrode 
array; peripheral nerve (CPT code 64555). 
 
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 your request is not medically necessary because there is little evidence in 
the medical literature to suggest that this is an appropriate procedure for the enrollee's knee pain. The Plan 
states it is not an accepted standard of medical practice for the diagnosis or treatment of knee pain and this is an 
experimental/ investigational procedure for the treatment of knee pain. 
 
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 service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the requested percutaneous implantation of neurostimulator electrode array; peripheral nerve 
(CPT 64555), in this case, is not medically reasonable or necessary.  
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve percutaneous implantation of neurostimulator electrode array; peripheral nerve (CPT code 
64555).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablation procedure (CPT 
code 64624) and conscious sedation (CPT code 99152). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says the clinical value and effectiveness of a genicular nerve radiofrequency ablation in the 
setting of right knee pain have not been demonstrated in the peer-reviewed literature. 
 
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 items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found genicular nerve ablation remains experimental for knee pain. More research is needed to show 
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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve genicular nerve radiofrequency ablation procedure (CPT code 64624) and conscious 
sedation (CPT code 99152).