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

 
We decided that the Plan does not have to pre-approve tocilizumab. 
 
You asked the Plan to pre-approve tocilizumab. You say that the short-term goal is to be able to wean off the 
chronic steroids while still maintaining remission. You also say that the longer-term goal is to keep the enrollee 
in remission without having to use steroids, that might be accomplished with the continued use of tocilizumab. 
The Plan denied your request. The Plan says the reasons why you want the enrollee to receive this medication 
are not medically accepted reasons. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 tocilizumab. Our reviewer says that 
tocilizumab is not medically reasonable and necessary for the enrollee. Our physician reviewer found the 
requested use of Tocilizumab is not FDA-approved for the enrollees diagnosis. Our reviewer also found that 
its use is not supported by one of the major drug compendia or by clinical research that appears in a Centers for 
Medicare & Medicaid Services (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 tocilizumab have not been met. Therefore, we decided that the Plan does not 
have to pre-approve tocilizumab.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vertiflex Superion interspinous spacer (22869) 
 
You asked the Plan to pre-approve Vertiflex Superion interspinous spacer. You say that this is medically 
necessary. The Plan denied your request. The Plan says this 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 Vertiflex Superion interspinous spacer. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found there is no compelling rationale presented or extenuating 
circumstances noted to support the medical necessity of this request as an exception. 
 
   
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 Superion interspinous spacer have not been met. Therefore, we 
decided that the Plan does not have to pre-approve Vertiflex Superion interspinous spacer (22869)
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for SelectMDx genetic testing provided on December 6, 2022. 
 
You asked the Plan to pay for SelectMDx genetic testing. You say that this test should be covered. The Plan 
denied your request. The Plan says this test has not met criteria for approval. 
 
The Plan must follow Medicare rules. Medicare rules say that the tests listed in the LCA have met coverage 
criteria. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SelectMDx genetic testing have not been met. Specifically, this test is not listed to meet criteria for 
approval in the LCA. Therefore, we decided that the Plan does not have to pay for SelectMDx genetic testing 
provided on December 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 0003A billed for date of service June 1, 
2022. 
 
You asked the Plan to pay for procedure code 0003A. You say that the testing should be reimbursed. The Plan 
denied your request. The Plan says the number of units billed exceeds the maximum allowed. The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 0003A is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 0003A have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 0003A billed for date of service June 1, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that it is medically necessary. The Plan denied your 
request. The Plan says the enrollee does not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollees nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for elective total hip replacement. Medical problems are stable. There are no complex nursing or 
rehabilitation needs. There is not a reasonable expectation that this enrollee will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel (87481, 
87556, 87640, 87798) provided on October 3, 2022. 
 
You asked the Plan to pay for the urine PCR panel. You say that this claim should be covered. The Plan denied 
your request. The Plan says this testing should be billed with a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a test panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This was a panel that was not billed with a single panel code as 
required. Based on this information, we decided that Medicare rules for coverage of the urine PCR panel have 
not been met. Therefore, we decided that the Plan does not have to pay for the urine polymerase chain reaction 
(PCR) panel (87481, 87556, 87640, 87798) provided on October 3, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code E0562 billed for date of service August 11, 
2022. 
 You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says an appropriate 
primary diagnosis code was not billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We find that CPT code E0562 was billed with primary diagnosis code G47.37, central sleep apnea in 
conditions classified elsewhere. This diagnosis code has a code first notation. This code is not permitted as a 
primary diagnosis code. 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 procedure code E0562 
billed for date of service August 11, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99285 billed for date of service September 5, 
2022. 
 You asked the Plan to pay for procedure code 99285. You say that this service was medically necessary. The 
Plan denied your request. The Plan says payment for code 99285 is bundled into payment for code 99223. 
 
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 99285 
is a column II code to column I code 99223. 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 99285 billed for date of service September 5, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for SelectMDx genetic testing provided on December 9, 2022. 
 
You asked the Plan to pay for SelectMDx genetic testing. You say that this test should be covered. The Plan 
denied your request. The Plan says this test has not met criteria for approval. 
 
The Plan must follow Medicare rules. Medicare rules say that the tests listed in the LCA have met coverage 
criteria. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SelectMDx genetic testing have not been met. Specifically, this test is not listed to meet criteria for 
approval in the LCA. Therefore, we decided that the Plan does not have to pay for SelectMDx genetic testing 
provided on December 9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on October 10, 
2022. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device provided on October 10, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that it is medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where the enrollee is currently receiving care. All medically necessary care is being provided in 
the current acute care setting. The requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
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.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for SNF care provided from July 25, 2022, to August 23, 2022. 
 You asked the Plan to pay for SNF care. You say that the enrollee would like reconsideration because the 
services are medically necessary. The Plan denied your request. The Plan says the enrollee no longer had 
skilled nursing facility needs. 
 
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 pay for 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 the enrollee did not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee did not require daily skilled nursing or skilled therapy on an inpatient basis in a SNF setting. 
 
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 pay for SNF care provided from July 25, 2022, to August 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99233 billed for date of service November 2, 
2022. 
 
You asked the Plan to pay for the billed services. You say that services were provided by multiple physicians. 
The Plan denied your request. The Plan says an appropriate modifier was not billed. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
The claim information shows that CPT code 99233 was provided by the same physician as minor procedure 
code 36558. CPT code 99233 was not billed with a modifier indicating a separate payment may be made. 
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 procedure code 99233 billed for date of 
service November 2, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a hospital bed and accessories (E1399). 
 
You asked the Plan to pre-approve a hospital bed and accessories. You say that the enrollee needs to stay 
elevated at night. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage 
of a hospital bed. 
 
The Plan must follow Medicare rules. The rules say that a hospital bed may be considered medically necessary 
when at least one of the following criteria is met: 
 
1. The patient has a medical conditions which requires positioning of the body in ways not feasible with an 
ordinary bed; or 
 2. The patient requires positioning of the body in ways not feasible with an ordinary bed in order to alleviate 
pain; or 
 
3. The patient requires the head of the bed to be elevated more than 30 degrees most of the time due to 
congestive heart failure, chronic pulmonary disease, or problems with aspiration. Pillows or wedges must have 
been considered and ruled out; or 
 
4. The patient requires traction equipment, which can only be attached to a hospital bed. 
 
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 hospital bed and accessories. Our 
reviewer says that a hospital bed is not medically necessary. Our physician reviewer found that the provided 
records in this case do not document the enrollee has a medical condition which requires positioning of the 
body in ways not feasible with an ordinary bed, or the enrollee requires the head of the bed to be elevated more 
than 30 degrees most of the time due to congestive heart failure, chronic pulmonary disease, or problems with 
aspiration, or the enrollee requires traction equipment, which can only be attached to a hospital bed. There is no 
documentation of the presence of (or a history of) pressure sores. There is no documentation that a bed length 
greater than a standard bed is medically necessary. There is no documentation that a bed light would serve a 
specific medical purpose that could not be met by a standard light. Thus, the enrollee does not meet criteria for 
coverage of this item. 
 
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 hospital bed and accessories have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a hospital bed and accessories (E1399).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve eight (8) additional occupational therapy visits. 
 
You asked the Plan to pre-approve eight (8) additional occupational therapy visits. You say that the resident 
would benefit from continued skilled occupational therapy to continue decreasing the resident's pain in bilateral 
hands. The Plan denied your request. The Plan says eight (8) additional occupational therapy visits are not 
medically necessary.  
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve eight (8) additional occupational 
therapy visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to 
prevent deterioration of the enrollee's condition. Our physician reviewer found the treatment program has been 
ineffective for the enrollee. There is no indication for continued input from a skilled therapist. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of eight (8) additional occupational therapy visits have not been met. Therefore, 
we decided that the Plan does not have to pre-approve eight (8) additional occupational therapy visits.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the enrollee does not meet medical necessity criteria 
for admission to an IRF. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee can walk 40 feet with minimal assistance. The enrollee has pain as a 
limiting factor and does not require intensive or complex rehabilitation services. Our reviewer also found the 
enrollee does not require frequent physiatry oversight.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an acute IRF admission and services.
Appeal type: Testing
Decision: Partially Favorable

 
We decided that the Plan has to waive the coinsurance for the drug injection provided on October 26, 2022. We 
also decided that the Plan does not have to waive the cost share for the EKG and testing supplies provided on 
October 26, 2022.  
 You asked the Plan to waive the cost share for the EKG, testing supplies, and drug injection. You say that you 
are only responsible for the $120 copayment for the cardiac stress test. The Plan denied your request. The Plan 
says that this cost sharing was charged correctly. 
 
We decided that the Plan has to waive the coinsurance for the regadenoson injection.  
 
You have been asked to pay 20% coinsurance for the regadenoson injection. According to Medicare, the 
injection (J2785) is considered a packaged code and is not separately payable. This code is also excluded from 
the physicians free schedule. Therefore, we decided that the Plan has to waive the coinsurance for the 
regadenoson injection provided on October 26, 2022.  
 
We also decided that the Plan does not have to waive the cost share for the EKG and testing supplies. 
 
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 $20 
copayment for outpatient non-radiological diagnostic tests. Your contract with the Plan also says that you must 
pay 20% coinsurance for diagnostic testing medical supplies. 
 
You have been asked to pay a $20 copayment for the EKG. You have also been asked to pay $184.74, which is 
20% coinsurance of the allowed amount for the medical supplies ($923.68 allowed amount x 20% coinsurance 
= $184.74). These items/services fall within the outpatient diagnostic tests and therapeutic services benefit 
category. Therefore, we decided that the Plan does not have to waive the cost share for the EKG and testing 
supplies provided on October 26, 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom shoe with lift/platform. 
 
You asked the Plan to pre-approve the custom shoe with lift/platform. You say that a shoe lift/platform would 
be beneficial for your steadiness and quality of life. The Plan denied your request. The Plan says this item is 
not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve a custom shoe with lift/platform.