Persius/hicric huggingface dataset:
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eylea (J0178). 
 
You asked the Plan to pre-approve Eylea. You say that the requested drug is medically necessary for the 
enrollee's condition. The Plan denied your request. The Plan says the enrollee has not tried and failed the 
preferred drug, Avastin. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Eylea. Our reviewer says that the step 
therapy criteria have not been met. Our physician reviewer found the provided documentation does not indicate 
that the enrollee has tried and failed the preferred drug. The reviewer found that there is no documentation 
provided indicating that the plans required drug 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 Eylea have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Eylea (J0178).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a peripheral nerve block (64450). 
 
You asked the Plan to pre-approve the injection. You say that you feel this procedure would benefit the 
enrollee. The Plan denied your request. The Plan says the requested service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the injection. Our reviewer says that the 
requested peripheral nerve block is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the role of genicular nerve blocks in the treatment of osteoarthritis of the knee is still 
being evaluated. The reviewer found that it is considered experimental or investigational at this time. 
Therefore, the requested injection 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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a peripheral nerve block (64450).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuation of SNF care. 
 
You asked the Plan to pre-approve a continuation of SNF care. You say that you are appealing the denial. 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 a continuation of 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 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. Records do not 
support that services in the home with home health care or in a long-term care facility on a part time basis are 
not appropriate in this case. 
 
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 a continuation of SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the moderate sedation services coded 99153 provided on 
May 14, 2022. 
 
You asked the Plan to pay for the moderate sedation services. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the services are not payable 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. 
 
We find that CPT code 99153 is not supported in the medical record. Specifically, this code has a professional 
component/technical component of 3. This indicator identifies stand-alone codes that describe the technical 
component of selected diagnostic tests for which there is an associated code that describes the professional 
component of the diagnostic tests only. Code 99153 was established as a practice expense-only code meaning 
there is no work component relative value unit (RVU) associated with that service.  Based on this information, we decided that Medicare rules for coverage of the moderate sedation services have 
not been met. Therefore, we decided that the Plan does not have to pay for the moderate sedation services 
coded 99153 provided on May 14, 2022.
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 the ventilator is medically necessary. The 
Plan denied your request. The Plan says the request for a home mechanical ventilator set in PS with Safety 
Tidal Volume that could be delivered by BiPAP is not covered. 
 
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 enrollee has COPD, although 
there are no pulmonary function tests to show severity. The enrollee was recently hospitalized with pneumonia.  
Initial ABG showed normal PaCO2 but subsequent ABG showed mild CO2 retention. There is no ABG done 
while stable to confirm chronic CO2 retention. If the enrollee does have chronic CO2 retention, he may benefit 
from BiPAP with AVAPS during sleep. Medicare does not cover a home ventilator when used as BiPAP. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve minimally invasive sacroiliac joint fusion services. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
enrollee has not had intensive non-operative treatment. 
 
The Plan follows Medicare rules. Medicare rules say that sacroiliac joint fusions are only covered under certain 
medical indications.  
 
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 requested services. Our physician 
reviewer found that there is no documentation of sacroiliac joint instability. Sacroiliac joint fusion for 
degenerative low back pain is experimental. Therefore, the request is 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve minimally invasive sacroiliac joint fusion services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lead wires (A4557) and electrical stimulator supplies 
(A4595) provided on June 1, 2022. 
 
You asked the Plan to pay for lead wires and electrical stimulator supplies. You say that you disagree with the 
denial and have submitted medical records for review. The Plan denied your request. The Plan says proof of 
delivery (POD) did not include an order number or details to corroborate the delivery ticket submitted. Of note, 
the POD is not itemized to indicate the specific supplies; therefore, the billed supply code cannot be verified. 
Unable to verify referring provider or any type of established relationship. 
 The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery, or relevant itemized specific supplies requested and 
provided by the referring provider in this case. The record shows that the Plan made several attempts to obtain 
the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for lead 
wires (A4557) and electrical stimulator supplies (A4595) provided on June 1, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93971 billed for date of service June 27, 
2022. 
 
You asked the Plan to pay for procedure code 93971. You say that you disagree with the Plan's denial. 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 3.  
 
In this case, the MUE for CPT code 93971 is 1. The MAI value for this code is 3. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 93971 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 93971 billed for date of service June 27, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service August 8, 
2022. 
 
You asked the Plan to pay for procedure code 76705. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says payment for code 76705 is bundled into 
payment for code 93976. 
 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 76705 
is a column II code to column I code 93976. 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 76705 billed for date of service August 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S8424 billed for date of service March 11, 
2022. 
 
You asked the Plan to pay for procedure code S8424. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says the billed codes are invalid for Medicare 
purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. Medicare rules say that a mastectomy sleeve (L8010) is denied as noncovered, since it does not meet the definition of a prosthesis. In addition, we 
find that procedure code S8424 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S8424 is not valid for Medicare purposes. 
 
Based on this information, we decided that Medicare rules for coverage of procedure code S8424 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code S8424 billed for date of 
service March 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro 2 Motion G arm orthosis (L8702). 
 
You asked the Plan to pre-approve a MyoPro 2 Motion G arm orthosis. You say that the requested item is a 
medical necessity for the enrollee. The Plan denied your request. The Plan says the requested item 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 a MyoPro 2 Motion G arm orthosis. 
Our reviewer says that the requested item is not considered medically reasonable and necessary in this case. 
Our physician reviewer found that current clinical guidelines designate robotic therapy to be of "uncertain 
utility compared with dose-matched conventional upper limb exercise therapies" with unproven benefit in the 
home environment. In addition, provided records report right upper extremity spasticity, which may be a 
contraindication to use of the device. 
 
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 MyoPro 2 Motion G arm orthosis have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a MyoPro 2 Motion G arm orthosis (L8702).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services (A0428, A0425) provided on March 4, 
2022. 
 
You asked the Plan to pay for ambulance services. You say that these services were necessary and were 
reported correctly. The Plan denied your request. The Plan says this claim was not submitted in accordance 
with Medicare billing guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules say that ground ambulance services 
should be reported with the most appropriate ICD-10 code that adequately describes the patient's medical condition at the time of transport, and a secondary diagnosis of Z74.01, Z74.3, Z78.1 or Z99.89 must also be 
reported. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of ambulance services have not been met. Specifically, this claim was submitted without a secondary 
diagnosis of Z74.01, Z74.3, Z78.1 or Z99.89 as required by the Local Coverage Determination. Therefore, we 
decided that the Plan does not have to pay for ambulance services (A0428, A0425) provided on March 4, 2022.
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 enrollee would benefit from skilled nursing 
services due to their medical complexity. The Plan denied your request. The Plan says the enrollee can be cared 
for in home with or without home care services or in a long-term custodial care facility. 
 
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 daily skilled services are not necessary. Our physician reviewer found that the 
medical records do not document that you require services on an inpatient basis, only in a skilled nursing 
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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room (ER) services rendered on July 11, 
2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of 
service (POS) code. 

We looked at the file and Medicare rules. The file shows that the claim was incorrectly billed with POS code 
49 (independent clinic). 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 pay for the emergency room 
(ER) services rendered on July 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Koya Dayspring non-pneumatic compression 
system. 
 
You asked the Plan to pre-approve the Dayspring compression system. You say that this device was found to 
meet the definition of durable medical equipment (DME) and was assigned payment codes in 2021. The Plan 
denied your request. The Plan says the requested device is considered experimental. 
 
Although Medicare indicated this meets the definition of DME and assigned codes to this system, this does not 
constitute an affirmative coverage decision. Medical necessity criteria must still be 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 the Dayspring compression system. Our 
reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is a 67-year-old patient with a diagnosis of chronic venous insufficiency 
and lymphedema. Based on the medical records provided and review of the current peer-reviewed medical 
literature (including Up to Date), there is no documentation that the Dayspring non-pneumatic gradient compression system at issue in this case meets all Medicare criteria for medically reasonable and necessary for 
the enrollee. Provided records and the current peer-reviewed medical literature (including Up to Date) do not 
document that the Dayspring non-pneumatic gradient compression system is standard of care for lymphedema 
or has shown long term health benefits for lymphedema patients in the Medicare population. 
 
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 Dayspring compression system have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the Koya Dayspring non-pneumatic compression system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dayspring active compression garment system. 
 
You asked the Plan to pre-approve a Dayspring active compression garment system. You say that this is 
medically necessary. The Plan denied your request. The Plan says this is experimental. 
 
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 Dayspring active compression 
garment system. Our reviewer says that the requested items are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the submitted records and the current peer-reviewed 
medical literature do not document that the Dayspring active compression garment system is standard of care 
for lymphedema or has shown long term health benefits for patients in the Medicare population with 
lymphedema.  
 
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 Dayspring active compression garment system have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a Dayspring active compression garment system.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SPRINT peripheral nerve stimulation (PNS) system. 
 
You asked the Plan to pre-approve SPRINT PNS system. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the requested services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SPRINT PNS system. 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 shoulder pain. The Sprint PNS system is experimental for 
chronic pain. More research is needed to show safety and efficacy. Therefore, the enrollee does not meet 
criteria for the requested 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 SPRINT PNS system have not been met. Therefore, we decided that the Plan 
does not have to pre-approve SPRINT peripheral nerve stimulation (PNS) system.