Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve CRT-D pacemaker (CPT code 33225). 
 
You asked the Plan to pre-approve the pacemaker. You say that the service is medically necessary. The Plan 
denied your request. The Plan says that the service is not 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 pacemaker. Our physician reviewer 
found authorization for the upgrade of the current end-of-life defibrillator to a system which allows bi-
ventricular pacing, either CRT-P or CRT-D, would be considered appropriate and reasonable 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 pacemaker have been met. Therefore, we decided that the Plan has to pre-
approve CRT-D pacemaker (CPT code 33225).  
 
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: 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 requested device is needed for COPD, 
chronic hypoxemic respiratory failure, and chronic hypercapnic respiratory failure. It was reported. that the 
enrollee was previously using a noninvasive ventilator when she was in a skilled nursing facility, but after 
discharge and not having the noninvasive ventilator at home, she worsened, requiring hospitalization. The Plan 
denied your request. The Plan says the requested device does not meet the requirements for approval. The 
records do not show evidence of failure of Bi-level PAP. The ventilator was ordered in a mode called volume 
assured pressure support (VAPS), and this can be achieved with bi-level devices such as a BiPAP machine. 
 
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 and was 
recently hospitalized with a suspected acute aspiration event. Imaging was suggestive of a primary lung cancer 
with metastases. The enrollee required intubation and was then placed on respiratory support with sleep after 
extubation. The records do not include an ABG documenting increased CO2, done while stable and awake. If 
this enrollee does have chronic CO2 retention, BiPAP with AVAPS, she may be of benefit. 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 the geniculate artery embolization of the knee for 
osteoarthritis (CPT code(s): 36247, 36245 and 36246). 
 
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the services are considered experimental and 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 the services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is limited published, large-scale, long-term peer-reviewed literature that shows this 
request to be an effective and/or safe treatment for the noted pathology. Further studies are needed to 
corroborate that this request is as good as or better than standard treatments. There is no compelling rationale 
presented or extenuating circumstances noted to support the medical necessity of this request as an exception. 
Therefore, the requested geniculate artery embolization of the knee for osteoarthritis, 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve the geniculate artery embolization of the knee for osteoarthritis (CPT code(s): 36247, 
36245 and 36246).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Zirabev, Doxorubicin, and Carboplatin. 
 
You asked the Plan to pre-approve Zirabev, Doxorubicin, and Carboplatin. You say that the services are 
necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria 
has not been met. 
 
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 Zirabev, Doxorubicin, and Carboplatin. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found the requested 
drugs are not FDA-approved for the enrollees diagnosis. There is no clear rationale for use. The enrollee 
completed 6 cycles of carboplatin and doxil on January 10, 2023. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Zirabev, Doxorubicin, and Carboplatin have not been met. Therefore, we 
decided that the Plan does not have to pre-approve Zirabev, Doxorubicin, and Carboplatin.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LINX surgery. 
 
You asked the Plan to pre-approve LINX surgery. 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 LINX surgery. 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 gastroesophageal reflux and Barrett's esophagus in the setting of prior partial 
gastrectomy.  There is insufficient literature to support the safety and efficacy of the requested service in the 
enrollee's specific clinical condition. 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 LINX surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve LINX surgery.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda. 
 
You asked the Plan to pre-approve Keytruda. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 Keytruda. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the drug 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 Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70544 billed for date of service January 7, 
2022. 
 
You asked the Plan to pay for procedure code 70544. You say that the claim should be paid. The Plan denied 
your request. The Plan says payment for code 70544 is bundled into payment for code 70551. 
 
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 70544 
is a column II code to column I code 70551. 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 70544 billed for date of service January 7, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes S5501 and S9550 billed for date of service 
September 26, 2022 to October 4, 2022. 
 
You asked the Plan to pay for procedure codes S5501 and S9550. You say that these services were billed 
correctly. 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. 
 
We find that procedure codes S5501 and S9550 have a Status Indicator of I on the Physician Fee Schedule. 
This means that procedure codes S5501 and S9550 are not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of procedure codes S5501 and S9550 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure codes S5501 and S9550 billed for 
date of service September 26, 2022 to October 4, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code A6219 billed for date of service September 1, 2022. 
 
You asked the Plan to pay for code A6219. The Plan denied your request. The Plan says code A6219 is 
considered bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that code A6219 has a status indicator of P on the Physician Fee Schedule. This means that code 
A6219 is not separately payable. Based on this information, we decided that Medicare rules for coverage of code A6219 have not been met. Therefore, we decided that the Plan does not have to pay for code A6219 billed 
for date of service September 1, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an electric connection for a power wheelchair (E2311). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says that since power tilt and recline and leg elevation feature includes a switch control and 
the enrollee is able to operate the switch controller, the upgraded electronic (expandable controller) is not 
needed. 
 
The Plan must follow Medicare rules. Medicare rules say that services are covered if they 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 pre-approve the services. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that the patient is non-ambulatory and requires a power wheelchair for mobility and performing his basic 
daily activities. He cannot adequately perform pressure relief independently due to limited range of motion and 
pain and requires a power wheelchair with power tilt. He also requires power elevating leg rests for positioning 
and lower extremity edema. The requested group two power wheelchair has both power tilt and a power 
articulating foot platform or leg rests. The controller is appropriate to coordinate the motion of these devices 
and there are two or more power options being utilized. Therefore, the electrical connection (E2311) is 
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 services have been met. Therefore, we decided that the Plan has to pre-
approve an electric connection for a power wheelchair (E2311).  
 
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: 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 the enrollee has chronic respiratory 
failure and consequences of chronic obstructive pulmonary disorder (COPD). You say that the enrollee will 
have life threatening condition and mobility if she is not on a non-invasive ventilator. You say that the enrollee 
has tried bi-level positive airway pressure (BiPAP) and was unstable. The Plan denied your request. The Plan 
says the home mechanical ventilator will be set in average volume-assured pressure support (AVAPS) mode 
with auto- expiratory positive airway pressure (EPAP) that could be delivered by BiPAP, and therefore is non-
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 portable ventilator. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee has been given 
diagnoses of obstructive sleep apnea (OSA), obesity hypoventilation syndrome, and chronic bronchitis.  There 
are no pulmonary function tests to establish a diagnosis of COPD and to assess severity.  There is no diagnosis 
of thoracic restrictive disease or neuromuscular disease.  There is no arterial blood gas (ABG), done while 
stable, indicating chronic carbon dioxide (CO2) retention.  A venous blood gas (VBG) is mentioned but 
detailed results are not provided.  If this patient does have chronic CO2 retention and severe COPD, they may 
benefit from BiPAP with AVAPS.  This has not been tried and failed. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve complete upper and lower dentures (D5110, 5120). 
 
You asked the Plan to pre-approve complete upper and lower dentures. You say that the items are necessary. 
The Plan denied your request. The Plan says the benefit for the requested items or services has already been 
exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service August 12, 2021. 
Therefore, we decided that the Plan does not have to pre-approve complete upper and lower dentures (D5110, 
5120).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for definitive drug testing of 8-14 classes (G0481) and 
presumptive drug testing, any number of drug classes (80307) provided on February 23, 2022. 
 
You asked the Plan to pay for definitive drug testing of 8-14 classes and presumptive drug testing, any number 
of drug classes. You say that this claim should be covered. The Plan denied your request. The Plan says these 
services do not meet coverage requirements. 
 
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 G0481 is definitive drug testing of 8-14 classes and 
80307 is presumptive drug testing of any number of drug classes. 
 
We find that CPT code G0481 and 80307 is not supported in the medical record. Specifically, it appears that 
more than 8-14 classes of drugs were tested. Based on this information, we decided that Medicare rules for 
coverage of definitive drug testing of 8-14 classes and presumptive drug testing, any number of drug classes 
have not been met. Therefore, we decided that the Plan does not have to pay for definitive drug testing of 8-14 classes (G0481) and presumptive drug testing, any number of drug classes (80307) provided on February 23, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing of 1-7 classes provided to the enrollee on June 1, 
2022. 
 
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. 
The Plan says this coding is not supported, as the claim documentation shows 23 classes. 
 
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 G0480 is "Drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and 
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 1-7 drug 
class(es), including metabolite(s) if performed." 
 
We asked our coder 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 testing. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found that in this case, the provider submitted a 
CPT code G0480 for 1-7 classes. The documentation indicates the testing was for 23 classes. The coding 
submitted by the provider does not match the laboratory test performed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have 
to pay for drug testing of 1-7 classes provided to the enrollee on June 1, 2022.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 99309 billed for dates of service September 14, 2022, 
to September 19, 2022. 
 
You asked the Plan to pay for procedure code 99309. You say that these services are supported in the medical 
record. The Plan denied your request. The Plan says that the number of units billed exceeds the maximum 
allowed. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be 
paid when the MAI value is 2. MUEs for codes with an MAI of 2 are absolute date of service edits. 
 
In this case, the MUE for CPT code 99309 is 1. The MAI value for this code is 2. You billed 1 unit of this code 
for date of service September 14, 2022, 1 unit for date of service September 16, 2022, and 1 unit for date of 
service September 19, 2022, which does not exceed the MUE. The Plan has provided no evidence to show that 
more than one unit has been billed per date of service at issue, nor has the Plan provided any other reason for 
denial in this case. Based on this information, we decided that Medicare rules for coverage of procedure code 
99309 have been met. Therefore, we decided that the Plan has to pay for procedure code 99309 billed for dates 
of service September 14, 2022, to September 19, 2022.  
 
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.