Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pre-approve intensity-modulated radiation therapy (IMRT) for hippocampal 
sparing. 
 
You asked the Plan to pre-approve the IMRT services. You say that the records provided support the need for 
the requested treatment. You say that hippocampal avoidance has been demonstrated to improve cognitive 
outcomes in randomized controlled phase 3 trial. You say that there are multiple benefits of hippocampal 
avoidance in sparing cognitive changes, especially given the enrollee's age. The Plan denied your request. The 
Plan says that the requested procedure is not medically necessary because there is no research that the enrollee's 
type of cancer responds better to the requested type of treatment. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the IMRT services. Our reviewer says 
that the requested IMRT services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the requested treatment should be offered in accordance with accepted standards of care, given 
the guidelines recognition of hippocampal sparing IMRT as a consideration in the setting of prophylactic brain 
radiation, and at least one randomized trial demonstrating a benefit. 
 
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 IMRT services have been met. Therefore, we decided that the Plan has to 
pre-approve intensity-modulated radiation therapy (IMRT) for hippocampal sparing.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for molecular genetic pathology testing (CPT code(s): 81220, 
81226, 81227, 81230, 81238, 81240, 81241, 81291, 81335, and 81355) provided on July 23, 2021. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
As CGP testing is not defined as a targeted panel by MolDX; and is a test not currently satisfactorily described 
by any existing CPT code; to report a CGP testing is not defined as a targeted panel by MolDX; and it is a test 
not currently satisfactorily described by any existing CPT code; to report a CGP, service providers should use 
1-unit only of CPT code 81479 (used for the entire bungled multi-test panel) at this time, in addition to the 
approved DEX Z-CodeTM entered adjacent in the comment/narrative field for the test; not unbundled to 
separate codes, or other unlisted code. Based on this information, we decided that Medicare rules for coverage 
of the services have not been met. Therefore, we decided that the Plan does not have to pay for molecular 
genetic pathology testing (CPT code(s): 81220, 81226, 81227, 81230, 81238, 81240, 81241, 81291, 81335, and 
81355) provided on July 23, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department visit for the evaluation and 
management of a patient (CPT code 99283) provided on October 21, 2021. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says the service is not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
CPT code 99283 is bundled to another service billed on the same day by a physician of the same specialty in 
the same billing group, which is considered the same provider. Procedure-to-Procedure code pair edits, code 
99283 is a column II to column I code 99284. 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 pay for the 
emergency department visit for the evaluation and management of a patient (CPT code 99283) provided on 
October 21, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Orthovisc injecitons (J7324) to be provided by an out-
of-network (OON) provider. 
 
You asked the Plan to pre-approve the orthovisc injections. You say that the injections are medically necessary. 
The Plan denied your request. The Plan says there are network providers available. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve Orthovisc 
injecitons (J7324) to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic office visit you had on June 29, 2021. 
 
You asked the Plan to pay for the visit. You say that you don't agree with the charges. The Plan denied your 
request. The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the chiropractic office visit you had on June 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator. 
 
You asked the Plan to pre-approve a portable ventilator. You say that home bilevel positive airway pressure 
(BiPAP) was considered but ruled out due to the severity of the enrollee's condition. The appellant says that the 
enrollee is oxygen dependent 24 hours a day, 7 days a week at three liters. The Plan denied your request. The 
Plan says a BiPAP with back-up rate in average volume-assured pressure support (AVAPS) mode is available 
and would meet all of the needs requested by the provider. 
 
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 portable ventilator. Our reviewer says 
that the criteria for coverage have not been met. Our physician reviewer found a home ventilator is not medically necessary. The enrollee has severe chronic obstructive pulmonary disease (COPD), but there is no 
documentation of chronic carbon dioxide (CO2) retention on an arterial blood gas (ABG) test done while the 
enrollee was stable. Medicare does not cover a home ventilator when used as BiPAP. There is no evidence of 
BiPAP failure. 
 
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 portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lupron Depot for the enrollee. 
 
You asked the Plan to pre-approve Lupron Depot. You say that this is medically necessary. The Plan denied 
your request. The Plan says that the enrollee does not have any stated contraindications to the preferred 
product. 
 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 Lupron Depot. Our reviewer says that 
Lupron Depot is not medically reasonable and necessary for the enrollee. The patient has not tried and failed 
Eligard. Eligard would not likely be less effective and/or likely have adverse effects for the enrollee. Our 
physician reviewer found that the enrollee's condition does not meet step therapy criteria for Lupron Depot. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Lupron Depot have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Lupron Depot for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Kanjinti. 
 
You asked the Plan to pre-approve Kanjinti. You say that this drug is medically necessary for the enrollee's 
condition. The Plan denied your request. The Plan says Kanjinti in combination with Gemcitabine is not a 
medically-accepted indication for the enrollee's condition. 
 
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 Kanjinti. Our reviewer says that the 
requested drug is not medically reasonable and necessary. Our physician reviewer found the enrollee is an 82-
year-old female diagnosed with gallbladder cancer in 2020. In this case, there is no support in the major drug 
compendia or by clinical research that appears in a Medicare-approved medical journal for the use of Kanjinti 
for the enrollee's condition. The current data supports only trastzumab/pertuzumab or trastuzumab + 
gemcitabine/cisplatin. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Kanjinti have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Kanjinti.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the targeted genomic sequence analysis panel (CPT code 
81455) provided on August 17, 2021. 
 
You asked the Plan to pay for the laboratory service. You say that the claim should be paid. The Plan denied 
your request. The Plan says the service is not covered. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the laboratory service have not been met. This genomic sequence 
analysis panel, CPT 81455 Targeted genomic sequence analysis panel, solid organ or hematolymphoid 
neoplasm, DNA analysis, and RNA analysis when performed, 51 or greater genes, is non-covered by Medicare. 
Genetic testing procedures submitted with code 81455 are unlikely to impact therapeutic decision-making in 
the clinical management of the patient and will be denied automatically as not medically necessary and 
screening testing. Therefore, we decided that the Plan does not have to pay for the targeted genomic sequence 
analysis panel (CPT code 81455) provided on August 17, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for physical therapy visits provided from 
November 3, 2021, to November 12, 2021. 
 
You asked the Plan to waive the copayments for physical therapy visits. You say that you were never informed 
of any out of pocket charges, otherwise you would have cancelled the therapy. You also say that your therapy 
referral was approved and then denied during therapy. The Plan denied your request. The Plan says you have 
been charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $5 
copayment for physical therapy visits at a comprehensive outpatient rehab facility. You have been asked to pay a total of $15, which is a $5 copayment for physical therapy visits on November 3, 
2021, November 10, 2021, and November 12, 2021. Physical therapy visits falls within the Outpatient 
Rehabilitation Services benefit category. This means that you have been asked to pay the correct amount based 
on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for physical 
therapy visits provided from November 3, 2021, to November 12, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a second emergency room visit (99284) provided on July 22, 
2020. 
 
You asked the Plan to pay for a second emergency room visit. You say that the enrollee visited the emergency 
department multiple times. The Plan denied your request. The Plan says only one visit is supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
We find that an additional unit of CPT code 99284 is not supported in the medical record. The medical record 
only supports 1 unit of CPT code 99284, which was previously billed and paid. Based on this information, we 
decided that Medicare rules for coverage of a second emergency room visit have not been met. Therefore, we 
decided that the Plan does not have to pay for a second emergency room visit (99284) provided on July 22, 
2020.
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 the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on SNF criteria. 
 
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 daily 
skilled services are not necessary. Our physician reviewer found you do not qualify for SNF coverage. You do 
not have documented skilled nursing needs. You do not have documented skilled therapy needs. You are not 
shown to have an acute decline in function. Daily skilled services are not shown to be required to establish a 
maintenance program or to prevent deterioration of your condition. Your care needs, custodial and intermittent, 
can, as a practical matter, be provided at a lower level of care. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections and fluoroscopic guidance (CPT 
code(s): 77002, 64493, 64494). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says your request is not medically necessary because your records show you do not have 
history of successful pain improvement from your prior facet injection procedures, for neither the amount nor 
duration required. The Plan states your provider says that your previous facet injections failed to adequately 
resolve your pain. 
 
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 physician reviewer 
found the most recent facet joint injections achieved only 40-50% pain relief without any report of the duration 
or improvement in function. The review has determined that the medical records provided do not meet the 
requirements listed in the LCD for Medicare 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 the services have not been met. Therefore, we decided that the Plan does not have to pre-approve facet joint injections and fluoroscopic 
guidance (CPT code(s): 77002, 64493, 64494).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 2 mattress (E0277). 
 
You asked the Plan to pre-approve the group 2 mattress. You say that the mattress 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 group 2 support surface is covered when medically 
necessary. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the group 2 mattress. Our reviewer says 
that the mattress is not medically necessary. Our physician reviewer found documentation does not support that 
the requested Group 2 support surface is medically reasonable and necessary for the enrollee in this case, as she 
does not have documented multiple stage 2 pressure ulcers on the trunk or pelvis which have not healed, large 
or multiple stage 3 or 4 pressure ulcers on the trunk or pelvis, or a myocutaneous flap or skin graft for a 
pressure ulcer on the trunk or pelvis within the past 60 days. 
 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 group 2 mattress have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a group 2 mattress (E0277).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that the member can remain in the current acute care location until 
such time no further acute level care is needed. 
 
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. The patient 
appears to be somewhat unstable and requires additional acute care services at this time that can be safely 
administered at the current facility until appropriate for a lower level of care. The patient does not require 
services at the LTACH that are not already available at the current facility. There are no services at the LTACH 
that the patient requires that are not already available and covered at the current facility. Our physician 
reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH 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 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 for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0676). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that the device is medically 
necessary. The Plan denied your request. The Plan says this device is non-covered. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pre-approve a pneumatic compression device (E0676).