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

 
We decided that the Plan does not have to pre-approve the insertion of an infusion pump to deliver pain 
medications. 
 
You asked the Plan to pre-approve the infusion pump. You say that this procedure is the enrollee's only option 
to decrease their pain and increase their daily functionality. The Plan denied your request. The Plan says the 
criteria for coverage have not been 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 infusion pump. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the request is for a Medtronic programmable intrathecal pump rather than a 
pressure driven pump. However, a bladder stimulator implanted in 2015 remains in place. The criteria for 
coverage does not permit another programmable device to be placed due to the risk of cross talk. 
 
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 infusion pump have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the insertion of an infusion pump to deliver pain medications.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve BRCA2 gene analysis; full duplication/deletion analysis 
(81167). 
 
You asked the Plan to pre-approve BRCA2 gene analysis; full duplication/deletion analysis. You say that you 
would like this testing done because your daughter was diagnosed with breast cancer. The Plan denied your 
request. The Plan says this service is not covered because you do not have a personal history of cancer. 
 
The Plan must follow Medicare rules. Medicare rules say that BRCA1/BRCA2 testing of an unaffected 
Medicare eligible individual or family member is considered not reasonable and necessary. 
 
We looked at the file and Medicare rules. In this case the record does not show that you have a personal history 
of cancer. Based on this information, we decided that Medicare rules for coverage of BRCA2 gene analysis; 
full duplication/deletion analysis have not been met. Therefore, we decided that the Plan does not have to pre-
approve BRCA2 gene analysis; full duplication/deletion analysis (81167).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve DePuy Synthes ViviGen allograft and bilateral open 
sacroiliac joint fusions. 
 
You asked the Plan to pre-approve DePuy Synthes ViviGen allograft and bilateral open sacroiliac joint fusions. 
You say that you have severe pain in both legs with limited mobility. You stated that you have loose screws 
from a previous surgery and a partially torn tendon in your right hip that affects your quality of life. You are 
now in bed 23 hours a day due to pain. The Plan denied your request. The Plan says it has approved lumbar 
laminectomy and spinal fusion procedures, but is denying the requested DePuy Synthes ViviGen allograft and 
bilateral open sacroiliac joint fusions. The clinical value and effectiveness of open sacroiliac joint fusion 
procedures in the absence of sacroiliac joint instability, fracture, or tumor presence have not been demonstrated 
in peer-reviewed literature. The clinical value and effectiveness of this allograft for use in spine surgery have 
also not been demonstrated in peer-reviewed literature. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.   
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve DePuy Synthes ViviGen allograft and 
bilateral open sacroiliac joint fusions. Our reviewer says that the requested items/services are not considered 
medically reasonable and necessary in this case. Our physician reviewer found while there are promising 
studies on this technology, a large variation in the type of surgery, outcomes collection, lack of control groups, 
and follow-up time prevented any significant conclusions from the studies. Thus, studies comparing the 
performance of allograft and demineralized bone matrix (DBM) to adequate controls in large, well-defined 
patient populations and with a sufficient follow-up time are needed to establish the efficacy of these materials 
as adjuncts to fusion. There is limited published, large-scale, long-term peer-reviewed literature that shows this 
requested allograft to be an effective and/or safe treatment for the noted pathology. Further studies are needed 
to demonstrate this request has beneficial outcomes compared with conventional treatment. There is no 
compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception. Therefore, the requested DePuy Synthes ViviGen allograft 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 DePuy Synthes ViviGen allograft and bilateral open sacroiliac joint fusions 
have not been met. Therefore, we decided that the Plan does not have to pre-approve DePuy Synthes ViviGen 
allograft and bilateral open sacroiliac joint fusions.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on May 15, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that the enrollee is in a nursing facility. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the laboratory services 
provided on May 15, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes A4556, A4557, A4649, A9279, S1015 and 
S8301 billed for date of service April 3, 2023. 
 
You asked the Plan to pay for procedure codes A4556, A4557, A4649, A9279, S1015 and S8301. You say that 
you disagree with the Plan's denial. The Plan denied your request. The Plan says the billed codes 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 procedure code. 
 
We find that codes A9279, S1015 and S8301 have a Status Indicator of I on the Physician Fee Schedule. This 
means that codes A9279, S1015 and S8301 are not valid for Medicare purposes. Codes A4556, A4557, and 
A4649 have a Status Indicator of P on the Physician Fee Schedule. This means that codes A4556, A4557, and 
A4649 are bundled/excluded and therefore, not payable as billed. Based on this information, we decided that 
Medicare rules for coverage of procedure codes A4556, A4557, A4649, A9279, S1015 and S8301 have not 
been met. Therefore, we decided that the Plan does not have to pay for procedure codes A4556, A4557, A4649, 
A9279, S1015 and S8301 billed for date of service April 3, 2023.
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 you are appealing with supporting 
records. The Plan denied your request. The Plan says the enrollee is unstable and has not yet completed the full 
course of care in the current hospital setting. 
 
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 is receiving appropriate services in the current acute care setting. 
Continued care in the current hospital is appropriate until the enrollee is stable for transfer to 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 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CTA scan of the coronary arteries. 
 
You asked the Plan to pre-approve the CTA scan. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when 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 CTA scan. Our reviewer says that 
the request is not medically necessary. Our physician reviewer found that the enrollee has no cardiac symptoms 
and ambulates in-full and is limited only by local foot pain from plantar fasciitis. Clinical guidelines for the use 
of CTA have not been met based on review of the documentation. As a result, at this time CTA imaging would 
not be considered medically reasonable and necessary in this enrollees 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 CTA scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a CTA scan of the coronary arteries.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the miscellaneous durable medical equipment, 
portable Hoyer patient lift (E1399) and sales tax (S9999) purchased November 17, 2022. 
 
You asked the Plan to reimburse you for the portable Hoyer patient lift . You say that you are appealing the 
denial of reimbursement. The Plan denied your request. The Plan says the item was purchased from a supplier 
that does not participate with Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to reimburse you for the miscellaneous durable 
medical equipment, portable Hoyer patient lift (E1399) and sales tax (S9999) purchased November 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 77387 billed for date of service March 20, 
2023. 
 
You asked the Plan to pay for procedure code 77387. The Plan denied your request. The Plan says the billed 
code is 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 code 77387 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 77387 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 77387 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 77387 billed for date of service March 20, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a surgical laparoscopy, repair of paraesophageal hernia 
(43282) to be provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve the surgical service. You say that you were approved for a consultation with 
this provider. You say that the surgery was denied. You also say that this provider only does surgery at one 
facility. The Plan denied your request. The Plan says this service can be provided in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The requested facility in this case is not in-network either. The Plan has network providers available who can provide the items/services at issue in 
this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, 
we decided that the Plan does not have to pre-approve a surgical laparoscopy, repair of paraesophageal hernia 
(43282) to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate services. 
 
You asked the Plan to pre-approve the requested services. You say that the services will significantly improve 
the enrollee's quality of life. The Plan denied your request. The Plan says the clinical efficacy has not been 
demonstrated. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
The file shows that bone marrow aspirate services were requested for use during spine fusion surgery. 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 bone marrow aspirate is experimental when used as bone graft material in spine surgery. 
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 bone marrow aspirate services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes U0005, 87502, 87503, 87486, 87541, 
87651, and 87798 billed for April 20, 2023. 
 
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 procedure codes U0005, 87502, 87503, 87486, 87541, 87651, and 877798 are not 
supported. 
 
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 U0005 is infectious agent detection by nucleic acid (dna 
or rna); severe acute respiratory syndrome coronavirus 2 (sars-cov-2) (coronavirus disease [covid-19]), 
amplified probe technique, cdc or non-cdc, making use of high throughput technologies, completed within 2 
calendar days from date of specimen collection (list separately in addition to either hcpcs code u0003 or u0004) 
as described by cms-2020-01-r2. The definition of code 87502 is infectious agent detection by nucleic acid 
(DNA or RNA); influenza virus, for multiple types or sub-types, includes multiplex reverse transcription, when 
performed, and multiplex amplified probe technique, first 2 types or sub-types. The definition of code 87503 is 
infectious agent detection by nucleic acid (DNA or RNA); influenza virus, for multiple types or sub-types, 
includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, each 
additional influenza virus type or sub-type beyond 2 (List separately in addition to code for primary procedure). 
The definition of code 87486 is infectious agent detection by nucleic acid (DNA or RNA); Chlamydia 
pneumoniae, amplified probe technique. The definition of code 87541 is infectious agent detection by nucleic 
acid (DNA or RNA); Legionella pneumophila, amplified probe technique. The definition of code 87651 is 
infectious agent detection by nucleic acid (DNA or RNA); Streptococcus, group A, amplified probe technique. 
The definition of code 87798 is infectious agent detection by nucleic acid (DNA or RNA), not otherwise 
specified; amplified probe technique, each organism. 
 
We find that CPT codes U0005, 87502, 87503, 87486, 87541, 87651, and 87798 are not supported in the 
medical record. Specifically, a panel of testing was performed and there is a more appropriate single code for 
the services. 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 procedure codes U0005, 87502, 87503, 
87486, 87541, 87651, and 87798 billed for April 20, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xgeva. 
 
You asked the Plan to pre-approve the medication. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says that step therapy requirements have not been met. 
 
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 the medication. Our reviewer says that 
the criteria for coverage of Xgeva have not been met. Our physician reviewer found that the Plan requires a 
trial of pamidronate and zoledronic acid before they will approve the requested drug. In this case, the enrollee 
has not tried and failed the required drugs. There is no documentation provided indicating that the Plan's 
required drugs would likely be less effective or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Xgeva.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve hyperbaric oxygen therapy. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says that the 
enrollee has measurable signs of healing.  
 
The Plan follows Medicare rules. Medicare rules say that hyperbaric oxygen therapy is 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 the enrollee is a diabetic with a nonhealing left foot ulcer. She has received multiple rounds 
of antibiotics for infection and debridement. The documentation also notes the enrollee has peripheral vascular 
disease. Due to comorbidities, the enrollee is at high risk for progression to necrotizing fasciitis and 
osteomyelitis. The enrollee only had minimal improvement in wound size with current management. Therefore, 
hyperbaric therapy is appropriate and 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 been met. Therefore, we decided that the Plan has to 
pre-approve hyperbaric oxygen therapy.  
 
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 procedure code 88321 billed for date of service May 24, 
2023.  
 You asked the Plan to pay for procedure code 88321. You say that the claims were billed by different 
physicians. 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 88321 is 1. The MAI value for this code is 2. You billed 2 units of this 
code on the same date of service, exceeding the MUE. Based on this information, we decided that Medicare 
rules for coverage of procedure code 88321 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 88321 billed for date of service May 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Outpatient Intravenous Insulin Therapy (OIVIT) services 
provided on June 15, 2023. 
 
You asked the Plan to pay for OIVIT services. The Plan denied your request. The Plan says the billed services 
are not supported. 
 The Plan must follow Medicare rules. The rules say that OIVIT is not reasonable and necessary for any 
indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered 
under Medicare when furnished pursuant to an OIVIT regimen. Therefore, we decided that the Plan does not 
have to pay for the Outpatient Intravenous Insulin Therapy (OIVIT) services provided on June 15, 2023.